Lemont Nursing & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a resident's urine specimen in a timely manner to rule out a urinary tract infection. This applies to 1 of 6 residents (R2) reviewed for quality of care. The findings include: R2's Face Sheet showed she was admitted to the facility on [DATE] and her diagnoses include history of UTIs (Urinary Tract Infections), ESBL (extended-spectrum beta lactamase) resistance, acute kidney failure, and anemia of chronic disease. R2's 1/21/25 nursing progress note from 5:08 PM showed .writer also spoke to resident's daughter [name] who said she talked to her mom and it was disturbing. She noted her mother seems paranoid and just wanted to let writer know. Writer informed daughter of my own interaction with her and daughter believes she could maybe have a UTI because 'this happens when she has a UTI ' Labs ordered to be drawn in the AM, urine to be collected per NP [Nurse Practitioner] . R2's 1/22/2025 Psychiatric Evaluation progress note from 12:16 PM (written…

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

Based on observations, interview and record review, the facility failed to provide personal hygiene to a resident that was dependant on care. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 6. The findings include: R1's face sheet included diagnoses of osteomyelitis, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, unspecified severe protein-calorie malnutrition, adult failure to thrive, other cerebral palsy, dysphagia, oropharyngeal phase, anorexia nervosa. R1's Annual MDS (minimum data set) dated November 06, 2024 showed that R1 was moderately impaired in cognition and was dependent on staff for all ADL's (activities of daily living) including personal hygiene. On 1/16/25 at 10:52 AM, when viewed through the door, R1 was seen lying in bed in hospital gown. Signage on R1's door showed Contact Isolation. V4 (Registered Nurse) who was in the hallway stated that R1 is on contact isolation for MRSA [Methicillin- resistant Staphylococcus Aureus) of wounds and gown and gloves are needed prior to room entry. On entry,…

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

Based on observations, interview and record review, the facility failed to serve pureed diet as ordered by a Physician to a resident (R1) that has had a recent history of swallowing problems. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 6. The findings include: R1's EMR (electronic medical records) included diagnoses of osteomyelitis, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, unspecified severe protein-calorie malnutrition, adult failure to thrive, other cerebral palsy, dysphagia, oropharyngeal phase, anorexia nervosa. R1's Annual MDS (minimum data set) dated November 06, 2024 showed that R1 was moderately impaired in cognition and was dependent on staff for all ADL's (activities of daily living) including eating. R1's diet order on POS (Physician Order Summary) showed Pureed diet (start date January 09, 2025). R1's weight (in lbs/pounds) history in EMR included as follows: 81.8 lbs (January 16, 2025), 89.8 lbs (December 17, 2024), 88.8 lbs (November 25, 2024), 89.6 lbs (October 18, 2024), 88.6…

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 128 residents in the facility receiving dietary services. Findings include: On 01/08/25 10:06 AM V1 Administrator confirmed 128 residents were being served from dietary services on 1/7/25. 1. On 01/07/25 at 10:01 AM, the dry storage contained: An opened one- gallon jar of mayonnaise dated 12/31/24 labeled refrigerate after opening. An opened one-gallon bottle of barbeque sauce dated 12/31/24 labeled refrigerate after opening. An opened 793-gram bag of chocolate pudding and a 24-ounce bag of butterscotch pudding without use by or opened on dates. Two 6-pound 9-ounce dented cans of yellow cling peaches. One 6-pound 3-ounce dented can of sauerkraut. On 01/09/25 at 01:15 PM, V21 (Dietary Director) stated the barbeque sauce and mayonnaise should be refrigerated once opened to prevent the growth of bacteria. Dented cans should be separated and not use because we don't know how deep the dent is or if the can was punctured 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 observations, interviews, and record reviews, the facility failed to provide grooming and hygeine cares for residents who require staff assistance. This applies to 5 of 7 residents (R64, R66, R76, R114, and R125) reviewed for activities of daily living (ADL) in a sample of 29. The Findings include: 1. R64 is an [AGE] year-old female admitted with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R1 is dependent for eating, toileting hygiene, oral hygiene, and personal hygiene. On 01/07/25 at 10:18 AM, R64 was observed in her bed with contracted hands, fingers curled, and nails about 7 millimeters (mm) past the fingertip, that were dirty with a brownish deposit underneath the nails, which were touching her palm. R64 stated that she wanted to trim her nails, but she couldn't do it alone, and nobody was helping her. On 1/8/25 at 9:37 AM, R64 was in her bed with a dry, crusty lip peeling off, and the resident was observed licking her dry lips. 2. R66 is…

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

Based on observation, interview, and record review, the facility failed to safely and securely store all resident medications. This applies to 11 residents (R64, R108, R74, R120, R37, R43, R72, R82, R5, R287, and R238) reviewed for medication storage in a sample of 29. Findings include: On 1/9/25 at 11:34 AM, the medication storage room on V14's (LPN/Licensed Practical Nurse) unit was checked in her presence. Upon entrance into the medication storage room, the medication refrigerator holding resident narcotics was found unlocked (narcotics were not double-locked) and the key to the refrigerator was hanging on a hook inside the medication storage room. V14 (LPN) said that is where the narcotic key is always kept. The following resident narcotics were found in the unlocked medication refrigerator: 1. R64's 2 vials of Lorazepam 2 mg/mL oral solution. 2. R108's Lorazepam 2 mg/mL oral solution. 3. R74's Lorazepam 2 mg/mL oral solution. 4. R120's Lorazepam 2 mg/mL oral solution. 5. R37's Lorazepam 2 mg/mL oral solution. On 1/9/25 at 11:41 AM, the medication storage room on V15's (LPN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain infection control practices that prevent the spread illness and disease. This applies to 6 of 7 residents (R20, R25, R29, R30, R32, R64 and R387) reviewed for infection control in a sample of 29. Findings include: 1. R32 admitted to the facility with diagnoses that includes Parkinson's, dementia, congestive heart failure, arthritis, left artificial hip joint and dysphagia. R32 physician's orders includes hospice care services and enhanced barrier precautions related to wounds. On 01/07/25 at 04:05 PM, R32's bedroom door had EBP (Enhanced Barrier Precautions) signage. There was no PPE (Personal Protective Equipment) located outside of the room or anywhere nearby for entering R32's bedroom. V17 Hospice CNA (Certified Nursing Assistant) was bathing R32 without wearing an isolation gown. V17 had thrown soiled linens on the floor near R32's bed. V17 stated there was no isolation gown available for her use. V17 stated she informed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to protect residents' privacy. This applies to 2 of 2 residents (R61 and R32) reviewed for dignity in a sample of 29. Findings include: 1. R61 admitted to the facility with diagnoses that includes effusion of the left knee, poly-osteoarthritis, acute kidney disease, dysphagia, anemia, hypertension, gout, and pulmonary edema. R 61's current care plan states he has an ADL (Activities of Daily Living) self-care performance deficit related to impaired gait and requires substantial staff assistance with transfers, bed mobility, and toileting. R61's MDS (Minimum Data Set) dated 1/5/25 shows he is cognitively intact. On 01/07/25 at 12:21 PM, R61's urine collection bag was hanging on the right side of his bed visible to the hallway. On 01/07/25 at 12:44 PM, V23 CNA (Certified Nursing Assistant) and a therapist came into room to put R61's pants on. R61's room blinds were left open and visible from the parking lot on the first floor as he was dressed.…

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 provide resident and/or their family/power of attorney (POA) in writing the reason residents were transferred to the hospital, and the facility failed to notify the ombudsman of resident hospital transfers. This applies to 3 of 3 residents (R25, R108 and R136) reviewed for hospitalization in a sample of 29. The findings include: 1. R108's Emergency Department (ED) hospital record of 11/21/24 shows that R108 was seen at the hospital for Altered Mental Status and Leukocytosis. R108's progress notes of 11/21/24 at 6:12 PM states that resident was confused and unable to acknowledge nursing staff. Resident's POA was notified and requested for resident to be sent to the hospital. Nurse informed the provider and the Director of Nursing (DON), orders received to send to the ED. 2. R25's ED hospital record of 1/3/25 shows that R1 was seen at the hospital for abdominal pain, ascites, and pneumonia. R25's progress notes of 12/31/24 at 4:45 PM states that R25 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide resident and/or their family/power of attorney (POA) written documentation of bed hold policy when residents were transferred to the hospital. The facility also failed to notify the ombudsman of resident transfer to the hospital. This applies to 3 of 3 residents (R25, R108 and R136) reviewed for hospitalization in a sample of 29. The findings include: 1. R108's Emergency Department (ED) hospital record of 11/21/24 shows that R108 was seen at the hospital for Altered Mental Status and Leukocytosis. R108's progress notes of 11/21/24 at 6:12 PM states that R108 was confused and unable to acknowledge nursing staff. Resident's POA was notified and requested for resident to be sent to the hospital. Nurse informed the provider and the Director of Nursing (DON), orders received to send to the ED. The facility was unable to provide documentation that the bed hold policy/assessment form was given to the resident and/or the POA upon transfer to 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, interviews, and record reviews, the facility failed to have an accurate MDS (Minimum Data Set) assessment to document the functional limitation in range of motion (ROM). This applies to two of the two residents (R66 and R64) reviewed for assessment accuracy in a sample of 29. The Findings include: 1. R66 is a [AGE] year-old male admitted with an admitting diagnosis, including cerebral infraction and hemiplegia affecting the right dominant side. On 01/07/25 at 12:03 PM, R66 was observed with his contracted right hand, third and fourth fingers curled and touching his palm. A review of R66's MDS dated [DATE] documented no impairment with functional limitation in range of motion. 2. On 01/07/25 at 10:18 AM, R64 was observed in her bed with contracted hands, fingers curled and touching her palm. A review of R64's MDS dated [DATE] documented no impairment with functional limitation in range of motion. On 01/08/25 at 9:59 AM, V8 (MDS Coordinator) stated, The hand contracture is coded 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 implement a physician's order for 1 of 1 residents (R239) reviewed for quality of care in a sample of 29. The findings include: R239 is a [AGE] year old female admitted to the facility on [DATE]th, 2024, with diagnoses including mechanical complications of nephrostomy catheter, calculus of kidney, hydronephrosis with ureteral stricture, urinary tract infection, and urge incontinence. On 1/7/25 at 2:11 PM, V9 (R239's daughter) said that she had concerns with the staff not changing the dressing to R239's nephrostomy every day. V9 turned R239 on her side and exposed R239's dressing to her nephrostomy. The date on the adhesive dressing showed 1/2/25 (five days earlier). V9 said, See, they are not changing it every day. On 1/8/25 at 12:04 PM, V6 (Wound Nurse) was preparing to provide wound care for R239. V6 turned R239 on her side, pulled down R239's pants, and opened her brief. Two adhesive dressings were present, one on the coccyx area and…

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

Based on observation, interview, and record review, the facility failed to have fall interventions in place for 2 of 5 residents (R3 & R94) who are at risk for falls in a sample of 29. The findings include: 1. On 01/7/25 at 11:25 AM, R3 was in her room and stated she had a concern with her bed moving when she tries to get into her bed from her wheelchair. R3 said that she grabs the Halo (specialized safety ring attached to the bed frame) at the top of her bed to pull herself up out of her wheelchair and stabilize herself to transfer into her bed. R3 said that every time she does it, her bed moves. The wheels on R3's bed were unlocked at this time and the bed moved easily when pushed. R3 stated she has a history of falling. R3's diagnoses include difficulty in walking, and lack of coordination. R3's 10/15/24 care plan showed that R3 is at risk for falls with interventions including the resident needs a safe environment. On 01/09/25 at 09:47 AM, V2 DON (Director of Nursing) said that the wheels on R3's bed should be locked to prevent her from falling. On 01/09/25 at 10:08 AM V2 (DON)…

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 attempt gradual dose reductions (GDR) for residents taking psychotropic medications. This applies to 2 of 3 residents (R82 and R109) reviewed for unnecessary medications/psychotropic medications in a sample of 29. The findings include: 1. Review of R109's Electronic Medical Record (EMR) shows the following diagnoses of traumatic brain injury, dementia, attention deficit hyperactivity disorder, bipolar disorder and major depressive disorder. R109's physician order shows that R109 has the following orders, Citalopram 20 mg give 1 tablet a day for antidepressant, Quetiapine 50 mg, give 1 tablet for bipolar disorder, Trazadone 150 mg give 1 tablet orally at bedtime for depression. Per the facility's Psychotropic and Sedative/Hypnotic Utilization report, it showed that R109 had GDR done on 4/14/24 for Citalopram 20 mg, Quetiapine 50 mg and Trazadone 150 mg. The next evaluation for GDR was supposed to be in October of 2024; there is no documentation that the…

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

Based on observation, interview, and record review, the facility failed to administer medications as ordered, in ordered dosages. There were 28 opportunities with 2 errors, resulting in a 7.14% error rate. This applies to 2 (R51 and R84) of the 5 residents observed in the medication pass. Findings include: 1. R51's Face Sheet shows diagnoses of dementia, atrial fibrillation, heart failure, cardiac pacemaker, hypertensive heart disease, and atherosclerosis. On 1/8/25 at 8:43 AM, V12 (LPN/Licensed Practical Nurse) administered two Potassium Chloride ER (extended release) 10 meQs (milliequivalents) tablets orally for a total of 20 meQs to R51. R51's POS (Physician Order Sheet) and MAR (Medication Administration Record) show an order dated/started 9/10/24 for Potassium Chloride 10 meQs ER 1 tablet orally two times a day (9 am and 5 pm). On 1/8/25 at 1:51 PM, V12 (LPN) said she gave R51 two 10 meQ tabs of potassium chloride, not 1 tab. V12 confirmed that she could see R51's POS showed an order to give one 10 meQ tablet of potassium chloride twice a day, but V12 had a note on the side of…

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

Based on observation interview and record review, the facility failed to provide a safe, comfortable, and homelike environment for 1 of 3 residents (R114) who were reviewed for environment in a sample of 29. The findings include: On 01/07/25 at 11:10 AM, R114 was observed in his bed and the bed control was observed wrapped around the Halo (specialized safety ring attached to the bed frame) on the right side of R114's bed. The wires to the cord were exposed about a foot in a half in length and one white wire was broken from the control. On 01/09/25 at 10:13 AM V2 DON (Director of Nursing) and the State Surveyor went into R114's room, R114 was in his bed, and the bed control was observed wrapped around the Halo on the top right side of R114's bed. V2 unwrapped the bed control and about 2 and ½ feet of the top of the cord was missing the protective plastic covering, exposing all of the wires. The white colored wire was broken away from the control. The bed control was plugged into the outlet. V2 said that the broken bed control was a safety issue. On 01/09/25 at 09:50 AM V2 said that…

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

Based on observation, interview, and record review, the facility failed to serve meal at the scheduled times. This applies to all 129 residents that receive food prepared in the facility kitchen. The findings include: 1. During entrance conference on April 1, 2024, the facility provided information that the census was 129 residents with no residents in house on NPO (nothing by mouth) status. On April 1, 2024, lunch service began after 1:45pm. On April 2, 2024, at 1:30pm, residents who are active in the Resident Council, including R51, R7, R26, R45, R50, R93, R95, and R108 met with this writer. During the meeting, R51 stated meals have been served as late as 2 hours after the scheduled time; all the other residents in the meeting affirmed R51's statement. R51 stated it gets quite late in the evening for dinner, as late as 8:00pm. 2. Facility Mealtimes schedule showed that the variable units would receive breakfast and lunch meals between 8:00-8:30 AM, and 12:00-12:30 PM respectively. On April 1, 2024, at 12:55 PM, the meal service was noted to start at the facility kitchen. When…

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

Based on observations, interview and record review, the facility failed to serve foods in a sanitary manner. This applies to all 129 residents that receive food prepared in the facility kitchen. The findings include: During entrance conference on April 1, 2024, the facility provided information that the census was 129 residents with no residents in house on NPO (nothing by mouth) status. 1. On April 1, 2024, starting at 9:53 AM, during initial tour of facility kitchen, V5 (Medical Records Director) was in the dietary office and stated that she is helping out with the meal tickets as the Dietary Manager is out on medical leave. V5 stated that she does not oversee the other functions in the kitchen. At the hand washing sink, there was a dirty rag inside the sink. Near the hand washing sink, the clean side of the dish machine area had extensive grime, and unknown debris. Two tray racks with washed glasses were stored over this same soiled area. V12 (Dietary Aide) was seen coming from outside the kitchen and stated that she went to collect the dirty dishes stored in the cart. V12 (not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide grooming and hygiene for residents who require assistance with ADL (Activities of Daily Living) care. This applies to 4 of 5 residents (R58, R60, R72, R100) reviewed for ADL care in the sample of 24. The findings include: 1. R100's Face sheet shows that R100 is a [AGE] year-old who has multiple medical diagnoses which include cerebral palsy and adult failure to thrive. R100's MDS (Minimum Data Set) dated January 30, 2024, showed that R100 was dependent on staff for ADL care. On April 1, 2024, at 11:53 AM, R100 was resting in bed, she had long dirty fingernails with brown and black unidentified substance underneath the nails, overgrown facial hair which was curling on the chin, uncombed greasy hair, and foul-smelling odor. On April 2, 2024, at 4:48 PM, R100 was resting in bed. She remained with overgrown nails, facial hair, long dirty fingernails, and a foul-smelling odor. V27 (Certified Nursing Assistant/CNA) stated that R100…

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

Based on observation, interview and record review, the facility failed to serve portions for mechanical soft fish as shown on menu spreadsheet. This applies to 5 of 5 residents (R16, R72, R100, R103, and R175) observed for dining in the sample of 24. The findings include: Menu spreadsheet for Fall Winter Menus (cycle day 23) for the mechanical soft diet showed to serve #6 scoop of ground baked fish with 2 oz/ounce gravy. On April 1, 2024, at 1:03 PM, during tray line service, the residents on mechanical soft diet received two scoops of ground fish served with a red handled spoodle and R16, R 72, R100, R103, R175 received the same. The same residents also did not receive gravy with the flaked fish. No menu spread sheet was seen in the meal service area. When asked, V8 (Cook) who was on the tray line serving the food, stated that the scoop yields 1 + 1/3rd oz/scoop. This showed that each resident on mechanical soft diet received 2 +2/3 oz/serving of mechanical soft fish. When V8 was shown the menu spreadsheet, he went looking for a #6 scoop and came back and stated that there are none…

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 hand hygiene and gloving during provisions of incontinence care. In addition, the facility failed to ensure staff donned full PPE (Personal Protective Equipment) when entering isolation rooms. This applies to 6 of the 24 residents (R26, R53, R58, R59, R100, R104) reviewed for infection control in the sample of 24. The findings include: 1. On April 1, 2024, at 2:57 PM, V33 and V34 (Both Certified Nursing Assistants/CNAs) rendered incontinence care to R58 who was wet with urine and had a bowel movement. V34 cleaned R58's peri-area from front to back then she (V34) opened the bathroom door with her soiled gloved hands to wash her gloved hands. After washing her gloved hands and without changing her gloves, V34 continued to clean R58. V33 on the other hand helped to clean the left side of R58's peri-area. After wiping R58, V33 changed her fecal stained gloves and did not perform hand hygiene. Both CNAs then repositioned R58 to the right side. V33 did…

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 provide documentation that influenza and pneumococcal vaccines had been offered. This applies to 5 of 5 residents (R26, R49, R53, R86, R104) reviewed for immunizations in the sample of 24. The findings include: 1. R86's EMR (Electronic Medical Record) showed R86, age [AGE], admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, dysphagia, atrial fibrillation, artificial opening of the urinary tract and urinary tract infection. On April 3, 2024, at 11:20 AM, V4 (IP Nurse) and V2 (DON) stated they were unable to provide documentation of influenza vaccine and pneumococcal vaccines were offered or declined, since admission for R86. V4 stated R86's family requested the vaccines be administered but was unable to provide documentation that the vaccines were administered. 2. R53's EMR showed R53, age [AGE], was admitted to the facility on [DATE], with multiple diagnoses including pneumonia, paroxysmal atrial fibrillation,…

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 notify the physician of a resident's pain and provide medication as ordered by the physician. This applies to 1 of 2 residents (R65) reviewed for pain management in a sample of 24. The findings include: 1. R65's Face sheet stated R65 was readmitted from the hospital on March 01, 2024, with diagnoses including encounter for other orthopedic aftercare, local infection of the skin and subcutaneous tissue, unspecified, acquired absence of left foot, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, non-pressure chronic ulcer of left ankle with unspecified severity, peripheral vascular disease. R65's 5-day MDS (minimum data set) dated March 7, 2024, showed that R65 was cognitively intact. R65's POS (Physician Order Sheet) included hydrocodone-acetaminophen 10-325 mg/milligrams [Norco]1 tablet every 4 Hours as needed (start date March 01, 2024). Physician progress note dated March 28, 2024 (Recorded as Late Entry on April 01, 2024) included as follows: Patient having a lot 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 monitor clinical condition of a resident upon returning from dialysis. The facility also failed to provide clinical documentation of resident's condition during dialysis treatment. This applies to 1 of 2 residents (R66) reviewed for dialysis in the sample of 24. The findings include: R66 is a [AGE] year-old male with medical diagnoses that include acute and chronic congestive heart failure, end stage renal disease, dependence on renal dialysis, morbid obesity, and type 2 diabetes mellitus according to the face sheet. Review of R66's physician orders showed there was no order for dialysis or for monitoring R66's dialysis access shunt site upon return from dialysis. On April 3, 2024, at 12:42 PM, V2 (Director of Nurses, DON) stated that R66's order for dialysis was not reactivated. V2 stated she would reactivate them now. On April 3, 2024, at 3:02 PM, V2 stated the facility does not have any reports from the dialysis company post dialysis sessions and no…

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 the diagnosis and specific behavior for residents who are prescribed antipsychotic medication. This applies to 3 of 5 residents (R32, R72, R99) reviewed for psychotropic medications in the sample of 24. The findings include: 1. R72's Face sheet shows that R72 is a 74 years-old who has multiple medical diagnoses which include parkinson's disease without dyskinesia and neurogenic disorder with lewy bodies, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Physician Order Summary (POS) shows multiple medications which include Quetiapine (antipsychotic medication) tablet 25 milligrams (mg) at bedtime. From April 2, 2024, through April 3, 2024, random observations were conducted on R72 between 9:35 AM through 3:00 PM. R72 was observed in the dining room either sleeping or sitting quietly. There was no behavior noted during observation. R72 was pleasantly confused when surveyor talked to him. On April 2, 2024, at 2:34 PM, V27 (Certified 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.

Based on observation, interview, and record review, the facility failed to ensure that a resident was not given Insulin belonging to another resident and failed to follow the facility's policy regarding medication administration. This applies to 1 of 1 resident (R115) reviewed for medication errors in the sample of 24. The findings include: On April 2, 2024, at 1:26 PM with V7 (Agency Nurse) outside of R115 room in the doorway, V7 asked R115 what his blood sugar was. R115 stated his blood sugar was 256. V7 stated R115 has an implanted monitor that shows his blood sugar. R115 stated he had lunch about 30 minutes ago. V7 apologized for being late. V7 stated, R115 blood sugar is high, I have to give him insulin. V7 stated she is going to give R115 five (5) units of Insulin Aspart. V7 (agency) looked for insulin in her cart and did not find any insulin and then said the insulin is in another cart. V7 then walked to another cart by the nurses' station and grabbed a box that had R65 name on it and showed it was Aspart Protamine 70/30. Inside the box there was a used multi-dose vial of…

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

Based on observation, interview and record review, the facility failed to provide substitute meals with the same nutrient content. This applies to 3 of 3 residents (R35, R86, R102) reviewed for dining in the sample of 24. The findings include: Facility Fall /Winter menus (week 4) for Monday showed Lemon Baked Fish as the main entree. Production recipe for the same showed to serve 1 filet of fish with a yield of minimum 2 oz (ounce) of protein. On April 1, 2024, at 12:50 PM, during lunch meal prep in the facility kitchen, V24 (Cook) was seen making grilled cheese sandwiches. V24 placed 2 slices of cheese in between two slices of bread and grilled it. R35, R86 and R102 were served the same on tray line. These residents' meal tickets showed written orders for grilled cheese and V24 stated they had ordered the same as a meal substitute for lemon baked fish. Facility Production recipe for Sandwich Cheese Grilled included to assemble sandwiches with 2.25 oz of cheese (3 slices of .75 ounces slices of cheese). On April 03, 2024, at 12:26 PM, V20 (Vice President of Culinary) stated that you…

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 physician-ordered negative pressure wound treatment system (wound vac) was placed for a resident with stage 4 pressure ulcers and failed to ensure a resident's stage 4 pressure ulcer was covered. This applies to 2 of 3 residents (R1, R2) reviewed for pressure ulcers. The findings include: 1.R1's Face Sheet showed she is a [AGE] year-old resident who was initially admitted to the facility on [DATE]. R1's progress notes showed she was sent to the hospital on 1/17/2024 to facilitate antibiotic treatment due to osteomyelitis and the lack of progressive healing of her wounds. R1's diagnoses include cerebral palsy, severe protein-calorie malnutrition, anorexia nervosa, pressure ulcer of sacral region stage 4, pressure ulcer of right buttock, stage 4 osteomyelitis, and adult failure to thrive. R1's 1/11/2024 Minimum Data Set (MDS) showed her cognition is moderately impaired. R1's Resident Face Sheet showed she was re-admitted to 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.