Odd Fellow-Rebekah Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to wear appropriate Personal Protective Equipment (PPE) when providing wound care for one (R46) resident on Enhanced Barrier Precautions (EBP) out of one resident reviewed for isolation precautions in a sample list of 45 residents. Findings include:R46's Electronic Medical Record (EMR) documents medical diagnoses as Atrial Fibrillation, Chronic Heart Failure, Non-Pressure Chronic Ulcer of the Right Foot and Peripheral Vascular Disease. R46's Minimum Data Set (MDS) dated [DATE] documents R46 as cognitively intact. This same MDS documents R46 requires moderate assistance with bed mobility, transfers and maximum assistance with toileting, bathing and dressing. R46's Physician Order Sheet (POS) dated November 2025 documents a physician order to Cleanse Right second toe with wound wash, do not scrub or use excessive force. Apply hydrogel to wound bed, then apply absorbent dressing and cover with absorbent pad, wrap with stretch gauze and secure…

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 palatable foods for four residents (R1, R4, R6, R7) out of four residents reviewed for Dietary Services in a sample list of ten residents. Findings include: The facility menu dated Week 1 Saturday (9/6/25) documents Beef and Noodles, Broccoli Florets, Bread/Margarine and Strawberry Rhubarb Crisp for lunch. The facility menu dated Week 3 Saturday (8/23/25) documents a supper meal of Pizza burger on bun, Italian Roasted potato wedges, pineapple tidbits and milk. The facility food temperature log for meal service dated 8/23/25 documents the meal/entree temperature was 200 degrees, vegetable temperature as 200 degrees, pureed meat temperature as 200 degrees and side (potatoes/rice, noodles/dressing) dish temperature as 202 degrees. 1.R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as being dependent on staff for total assistance for eating, oral hygiene, dressing,…

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 and showers timely for two residents (R1, R2) out of three residents reviewed for Activities of Daily Living (ADL) in a sample list of ten residents. Findings include: 1.R1's undated Face Sheet documents R1 admitted to the facility on [DATE] and was discharged on 8/30/25. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as being dependent on staff for total assistance for eating, oral hygiene, dressing, bathing, toileting and bed mobility. R1's Care Plan interventions dated 8/22/25 instruct staff to provide/assist R1 with grooming/hygiene daily and as needed. Give/assist shower/bath twice per week or as often as (R1) prefers.The facility was unable to provide any documentation of R1 being provided a shower/bed bath from 8/21/25-8/25/25.On 9/6/25 at 9:00 AM V4 (R1's) Power of Attorney (POA) stated R1 was admitted to the facility from a hospital on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to complete a wound assessment, monitor skin integrity, and prevent cross contamination during wound care and incontinence care for three of three residents (R1, R2, R3) reviewed for pressure sores in the sample list of ten residents. Findings include:1.R1's undated Face Sheet documents R1 admitted to the facility on [DATE] and was discharged on 8/30/25. R1's Electronic Medical Record (EMR) documents R1's medical diagnoses as Muscle Wasting, Nontraumatic Intracerebral Hemorrhage, Diabetes Mellitus Type II, Atrophy, Convulsions, Chronic Vascular Disorders of Intestine, Chronic Obstructive Pulmonary Disease (COPD), Urinary Tract Infection (UTI), Dysphagia Oral Phase, Hypertension, Depression, Dependence on Supplemental Oxygen, Gastrostomy Status, Neuromuscular Dysfunction of Bladder, Acute Respiratory Failure with Hypoxia, Chronic Kidney Disease, Glaucoma, Anemia and Hyperkalemia. R1's admission assessment dated [DATE] does not document a…

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 wear the appropriate Personal Protective Equipment (PPE) during pressure ulcer care for two (R2, R3) residents on Enhanced Barrier Precautions (EBP) out of three residents reviewed for pressure ulcers in a sample list of ten residents.Findings include:1.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 is dependent on staff for total assistance with eating, oral hygiene, dressing, bathing, toileting, bed mobility and transfers. R2's Care plan intervention dated 7/24/25 documents R2 is on Enhanced barrier precautions per Center for Disease Control (CDC) guidelines, due to presence of Supra-pubic catheter, wounds and colostomy. On 9/6/25 at 2:00 PM R2's room door did not have a sign posted for Enhanced Barrier Precautions (EBP). There were no Personal Protective Equipment (PPE) supplies outside R2's room nor were there any PPE easily accessible. On 9/7/25 at 9:30 AM R2's room…

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 protect the resident's right to be free from physical abuse by another resident for two of three residents (R2, R3) reviewed for abuse in the sample list of five.Findings Include:The Facility Abuse Prevention and Reporting policy effective 3/15/2018, documents this facility affirms: 1. All residents have the right to be free of from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. On 8/23/25 at 12:23pm R2's Care Plan documents an admission date of 03/14/2023 with diagnoses of Muscle Weakness (generalized), Type II Diabetes Mellitus with Diabetic Neuropathy, Paroxysmal Atrial Fibrillation, Hyperlipidemia, Glaucoma, Essential (Primary) Hypertension, Hypothyroidism, Chronic Kidney Disease, Acquired Absence of Right Leg Below Knee, Chronic Diastolic (Congestive) Heart Failure, and Acquired Absence of Left Leg Below Knee. On 8/23/25 at 12:27pm R3's Care Plan documents an admission date of 08/11/2022 with diagnoses 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 interview and record review, the facility failed to develop a comprehensive, person-centered care plan for trauma/abuse for one of three residents (R2) reviewed for abuse in the sample list of five.Findings include:The Care Plan Process policy dated 11/2017 documents a comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs, while honoring resident rights to choice. This care plan shall include goals, measurable objectives, and interventions to meet identified resident needs. The same document states all plans of care must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessment.On 8/23/25 at 12:23pm R2's care plan documents an admission date of 03/14/2023 with diagnoses of Muscle Weakness (generalized), Type II Diabetes Mellitus with Diabetic Neuropathy, Paroxysmal Atrial Fibrillation, Hyperlipidemia, Glaucoma, Essential (Primary) Hypertension,…

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 physician ordered treatment and services for a non-pressure abdominal wound. This failure affects one resident (R1) out of three reviewed for skin conditions and treatments on the sample list of five. Findings include: R1's Nurses Notes dated 7/2/2025 at 12:30 PM documents the nurse on duty was notified by the night shift nurse that this resident (R1) had an open area noted to her left side. The open area was noted to be 1 centimeter by 3 centimeters area to left lower abdomen. R1's Nurse Practitioner was notified and the open area was cleaned with wound wash, covered with xeroform and covered with border foam and the treatment will continue until healed. R1's current Physician Order Sheet dated for July 2025 documents a physician order for R1 to receive a treatment for an abdominal wound described as, Cleanse area to left lower abdomen with wound wash/normal saline, apply Xeroform dressing and cover with border foam daily, until healed, every day shift. This physician ordered treatment was dated as…

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 physician ordered treatments and services to aid in the healing of a pressure ulcer. This failure affects one resident (R1) out of three reviewed for skin issues and treatments on the sample list of five. Findings include: R1's current Physician Order Sheet dated for July 2025 documents treatments for R1's pressure ulcer on the left heel as, Cleanse area to left heel with wound wash or normal saline, apply collagen to wound bed and cover with border foam, every day shift and Float heels on pillow at all times. On 7/15/25 at 11:15 AM, R1 had a dressing on her left heel that was dated 7/13 (2025). R1 did not have a pillow present under her legs or feet to float her heels off of the bed surface. On 7/15/25 at 11:15 AM, V2, Director of Nursing, confirmed the date on R1's heel dressing was 7/13. V2 further confirmed there was no pillow present to float R1's heels off of the bed surface. V2 stated the wound on R1's left heel was a pressure ulcer. R1's Treatment Administration Record dated for July 2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medications as ordered by the prescriber and in a timely manner for four of four residents (R1, R2, R3, R4) reviewed for medication administration in a sample list of eleven. Findings include: 1.) On 10/29/24 at 2:36 PM, R1 stated the nurses give her medications at different times. R1 stated R1 never knows when she will get her medications or what she is getting. R1 stated, she has been woken up in the middle of the night to get medications but states she does not take any medications that late. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. R1's October 2024 Medication Administration Record (MAR) documents orders for R1's medications as follows: at 8:00 AM every morning, R1 is to receive Cholecalciferol (vitamin D) 25 micrograms (mcg), Amiodarone (anti-arrhythmic) 200 milligrams (mg), Furosemide (anti-hypertensive) 20 mg, Multivitamin 1 capsule, Apixaban (anticoagulant) 5 mg, Metoprolol (hypertension/heart…

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 clean homelike environment by failing to maintain clean walls and repair broken floor tiles in the facility's [NAME] shower room. This failure affects 49 residents (R1-R49) reviewed for homelike environment in the sample list of 49. Findings include: The facility's Shower and Tub Room Cleaning policy dated 11/1/12 documents, This procedure will remove soap scum, dirt and debris from these areas providing a safe and sanitary place for the residents to bathe. This policy documents that the shower stalls are to be cleaned daily with disinfectant solution. This policy also documents that it may be necessary to use a scrub brush or machine with an all-purpose or tub/tile cleaner on walls monthly to remove residue from grout corners. On 10/15/24 at 10:38 AM, R1 stated that there is (black substance) between the tiles in the shower room and it smells like mildew in there. On 10/15/24 at 10:54 AM, V9 Certified Nursing Assistant stated there is (black substance) in the shower room on the tiles and 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 interview and record review, the facility failed to provide follow-up care for residents who continued to have behaviors despite non-pharmacological interventions being used for four residents (R9, R16, R101, R104) and failed to refer a resident (R18) to behavioral health services after R18 made a suicidal statement. These failures affected five residents (R9, R16, R18, R101, R104) out of six residents reviewed for behavioral health services in a sample list of 75 residents. Findings include: The facility's Condition Change Documentation Policy dated 9/28/09, documents to maintain a medical record that is reflective of documentation of the care provided to resident's to include notifications related to the change of a resident's condition; documents any nursing interventions or treatments provided to the resident as indicated by the nature of the condition and current physician orders; notify the physician of change of condition and document any physician orders received. 1). R9's undated Medical…

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 only licensed personnel had access to the west hall medication room keys. This failure had the potential to affect all 46 of 46 residents (R1, R2, R3, R6, R7, R8, R10, R11, R13, R17, R18, R23, R25, R26, R29, R30, R33, R42, R45, R48, R50, R53, R54, R57, R60, R62, R63, R65, R70, R72, R74, R76, R77, R79, R81, R84, R85, R86, R93, R100, R103, R105, R113, R143, R152, and R321) reviewed for west hall, medication storage on the sample list of 75. Findings include: On 10/3/24 at 1:00 pm, V28, Certified Nursing Assistant (CNA) approached V25, Licensed Practical Nurse (LPN) on the west hall of the facility. V28, CNA asked for the west hall medication room keys. V28 stated he needed to get ice packs for a resident (unidentified). V25, LPN handed V28, CNA the medication room door keys, without hesitation. V28, CNA walked down the hall approximately 50 feet to the nurses station, turned right, out of V25, LPN sight, and walked over ten feet to the medication room door. This surveyor followed V28, CNA while V25, 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 wear the appropriate Personal Protective Equipment (PPE) during medication administration for a resident (R224) on Contact Isolation Precautions, failed to properly dispose of contaminated PPE for a resident (R321) on Enhanced Barrier Precautions (EBP), failed to complete hand hygiene during wound care and catheter care for a resident (R26) on EBP and failed to wear the appropriate PPE during incontinence care and catheter care for a resident (R17) on EBP. These failures affect four (R17, R26, R224, R321) out of four residents reviewed for infection control in a sample list of 75 residents. Findings include: The facility policy titled Contract Precautions Protocol revised July 26, 2021 documents a gown should be worn when it is anticipated that clothing will have substantial contact with the resident, environmental survfaces, or items in the resident's room, or if the resident is incontinennt or wound drainage is not contained by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify a residents Physician timely for the residents fall with injury. This failure affects one (R171) out of five residents reviewed for falls in a sample list of 75 residents. Findings include: R171's undated Face Sheet documents medical diagnoses as Vascular Dementia, Unsteadiness on Feet, Muscle Wasting and Atrophy, Abnormalities of Gait and Mobility, Obstructive and Reflux Uropathy, Presence of Urogenital Implants, Venous Thrombosis and Embolism, Transient Ischemic Attack (TIA), Cerebral Infarction, Long Term Use of Anticoagulants and Anxiety Disorder. R171's Minimum Data Set (MDS) dated [DATE] documents R171 as severely cognitively impaired. This same MDS documents R171 as requiring maximum assistance with toileting and moderate assistance with bathing, dressing, personal hygiene and bed mobility. R171's Careplan intervention dated 2/23/24 documents (R171) may transfer and ambulate with one assist, assistive device and gait belt. R171's Fall Risk…

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 complete a recapitulation of stay for one (R118) resident out of one resident reviewed for discharge in a sample list of 75 residents. Findings include: The facility policy titled Discharge Record Processing revised 10/25/2022 documents a Discharge Summary is to be completed and signed by the Physician. All discharged records should be completed within 30 days of discharge. R118's undated Face Sheet documents R118 admitted to the facility on [DATE] and discharged on 7/3/24. R118's Minimum Data Set (MDS) dated [DATE] documents R118 as moderately cognitively impaired. R118's Electronic Medical Record (EMR) does not include documentation of a recapitulation of stay. On 10/4/24 at 11:15 AM, V2 Director of Nurses (DON) stated the recapitulation of stay was not completed for R118. V2 DON stated anytime a resident discharges there is a specific form that is completed which includes the discharge summary/recapitulation of stay and this was not completed for…

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

Based on observation, interview and record review the facility failed to apply physician ordered compression stocking for one of one residents (R81) reviewed for edema on the sample list of 75. Findings include: R81's diagnoses sheet dated 10/04/24 documents the following diagnoses: Bilateral Primary Osteoarthritis of the Knee, Type II Diabetes Mellitus Without Complications, Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity. R81's Physician Order Summary Report dated 10/04/24 documents the following: Apply bilateral (name brand compression) hose in the morning and remove at bedtime. On 10/4/24 at 10:47 am, R81 was seated in a wheelchair bedside with non-skid socks on that had been slit at each heel. R81's feet were visibly swollen. R81 stated she was agitated because an unidentified Certified Nursing Assistant (CNA) put non-skid socks on R81, instead of R81's compression hose. On 10/4/24 at 11:03 am, V25, Licensed Practical Nurse confirmed R81 does not have R81's compression hose on, as the physician ordered. V25 stated The CNA's are suppose to put…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess and monitor (R10, R18) pressure ulcers and failed to provide (R26) a pressure relief chair cushion. These failures affected three of six resident (R10, R18, R26) reviewed for pressure ulcers on the sample list of 75. Findings include: 1.) R26's Minimum Data Set (MDS) dated [DATE] documents R26's Brief Interview of Mental Status score as 13 out of a possible 15, indicating no cognitive impairment. The same MDS documents Skin and Ulcer/Injury Treatment check all that apply; The box for pressure reducing device for a chair, is checked. R26's Braden Scale - for Predicting Pressure Ulcer Risk Evaluation dated 9/3/24 documents R26 is at risk for developing pressure ulcers. R26's Physician Order Sheet documents the following treatment orders: 1. Cleanse open fistula area on L (left) hip with wound wash or NS (normal saline), apply collagen to wound bed then apply Calcium Alginate et (sic), cover with Border (bordered) foam. (Do Not apply…

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 care plan interventions and failed to label enteral feeding bottles for two (R84, R321) out of two residents reviewed for Gastrostomy tubes (G-tube) in a sample list of 75 residents. Findings include: The facility policy titled Enteral/Tube Feeding Policy revised 2/26/2015 documents feeding solutions will be stored at room temperature until opened at which the feeding will be labeled to include the date and time the formula was opened. To prevent retrograde contamination from resident into a feeding bag container, keep the head of the bed elevated 30-45 degrees during feeding and for 30-60 minutes after feeding. 1.) R84's Minimum Data Set (MDS) dated [DATE] documents R84 as cognitively intact. This same MDS documents R84 requires maximum assistance with toileting, bathing, dressing and moderate assistance with personal hygiene and bed mobility. R84's Care plan intervention dated 11/3/22 documents R84's head of bed should be…

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 administer medications per the physician order for one (R321) resident out of five residents reviewed for medication administration in a sample list of 75 residents. This failure resulted in two medication errors out of 26 opportunities, 7.69% medication error rate. Findings include: The facility policy titled Medication Administration dated 1/11/2010 documents the facility will accurately administer medication following Physician's orders. R321's undated Face Sheet documents R321's medical diagnoses as Encephalopathy, Ischemic Cardiomyopathy, Heart Disease, Muscle Wasting and Atrophy, Acute Kidney Failure, Esophageal Obstruction, Diabetes Mellitus Type II, Other Specified Disease of the Pancreas, Pneumonia, Pleural Effusion, Peritoneal Abscess, Pneumonitis due to Inhalation of Food and Vomit, Chronic Diastolic Congestive Heart Failure, Cardiac Vascular Implant and Graft, Gastroesophageal Reflux Disease (GERD), Implanted Cardiac…

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 for the dignity of residents during incontinence care. This failure affects two (R1, R7) out of five residents reviewed for Activities of Daily Living (ADL) in a sample list of eight residents. Findings include: The facility policy titled Resident Dignity reviewed 9/2011 documents all residents have the right to have their privacy maintained irrespective of their functional and cognitive status. Staff will respect this right in the following ways: knock on room door prior to entry and request permission to enter, screen all care provided at the bedside, and close drapes, privacy curtains and room doors as necessary to maintain privacy. 1.) R7's Minimum Data Set (MDS) dated [DATE] documents R7 as severely cognitively impaired. This same MDS documents R7 as dependent on staff for assistance with dressing, bed mobility, bathing, toileting, maximum assistance needed for personal hygiene and requires the assistance of staff using a…

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 Activities of Daily Living (ADL) for two (R1, R7) residents out of five residents reviewed for ADL's in a sample list of eight residents. Findings include: 1.) R1's undated Face Sheet documents medical diagnoses as Hypertension, Difficulty in Walking, Diabetes Mellitus Type II, Gastroesophageal Reflux Disease (GERD), Muscle Weakness, Muscle Wasting and Atrophy, Chronic Kidney Disease, Repeated Falls, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Spinal Stenosis, Trans Ischemic Attack (TIA), Cerebral Infarction, Protein Calorie Malnutrition and Urinary Tract Infection. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively intact. This same MDS documents R1 as dependent on staff for toileting, bathing, eating, dressing and transfers with the assistance of two staff and a total body mechanical lift. On 8/17/24 at 12:15 PM, R1 sitting in highback reclining wheelchair at dining room table. R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide timely incontinence care for one (R1) resident out of five residents reviewed for incontinence cares in a sample list of eight residents. Findings include: R1's undated Face Sheet documents medical diagnoses as Hypertension, Difficulty in Walking, Diabetes Mellitus Type II, Gastroesophageal Reflux Disease (GERD), Muscle Weakness, Muscle Wasting and Atrophy, Chronic Kidney Disease, Repeated Falls, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Spinal Stenosis, Trans Ischemic Attack (TIA), Cerebral Infarction, Protein Calorie Malnutrition and Urinary Tract Infection. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively intact. This same MDS documents R1 as dependent on staff for toileting, bathing, eating, dressing and transfers with the assistance of two staff and a total body mechanical lift. On 8/18/24 at 8:30 AM, R1 was reclined back in his wheelchair sitting at the dining room table. 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 interview and record review the facility failed to obtain a consent and initial assessment for an antipsychotic, psychotropic medication for one (R1) of three residents reviewed for psychotropic medications. Findings include: The facility Psychotropic Medication Policy dated 11/28/17 documents that an evaluation must be done to determine other possible physical, mental, behavioral and psychosocial needs before administering a psychotropic medication. Symptoms and therapeutic goals must be identified and documented and an evaluation by the physician and consultant pharmacist for the use of the medication and whether a reduction or discontinuation can occur. The ongoing evaluation of the effectiveness of the medication should also be monitored. R1's physician orders dated December 29, 2023 document an order for five milligrams (mgs) of Abilify (an antipsychotic, psychotropic medication) to be given by mouth every morning for dementia. R1's December 2023 and January 2024 medication administration records document that 5mgs of Abilify was administered to R1 from December 29,…

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 consistent oral/dental care for a dependent resident. This failure affected one of three residents (R1) reviewed for oral care in the sample of three. Findings Include: The facility's Morning Care policy dated April 2009 documents staff are to provide personal hygiene in the morning. Staff are to provide or assist residents with oral hygiene which includes oral care and cleaning dentures. R1's Medical Diagnoses List dated January 2024 documents R1 is diagnosed with Cerebral Infarction, Hemiplegia and Hemiparesis Left Side, Aphasia, Heart Failure, Muscle Weakness, Insomnia, Tremor, and Depression. R1's Care Plan dated 11/8/23 documents R1 has upper dentures and natural lower teeth and requires assistance with oral care, teeth brushing, and denture care. The same Care Plan documents R1 is at risk for self care deficit and requires assistance with grooming and hygiene daily and as needed. R1's Nurse Progress Notes dated 12/27/23 and 1/4/24 document R1 voiced complaints of oral/tooth pain. R1's Nurse Progress Note dated…

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 prevent potential cross contamination of foods served during meal service. This failure has the potential to affect all 117 residents residing in facility. Findings include: The Facility Daily Census Report dated 12/4/23 documents 117 residents reside in facility. On 12/4/23 at 10:45 AM-11:40 AM V12 [NAME] wore same pair of disposable gloves throughout entire meal service. V12 [NAME] left steam table four separate times to retrieve items needed for food service and then continued to serve resident meals without washing hands, or using alcohol based hand rub. V12 [NAME] used contaminated disposable gloves to pick up thermometer that was laying on back counter to obtain temperature of pans of foods that needed replaced on food line during lunch service. V12 [NAME] used same gloved hands to hold onto oven mitts to move pans of hot foods from warming oven to steam table and then continued to serve resident meals. V12 [NAME] used same contaminated gloved hands to reach into plastic bag of frozen breaded chicken…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the State Ombudsman for one (R87) of four residents reviewed for hospitalizations in a sample list of 58 residents. Finding include: 1.) R87's Medical Diagnoses List documents R87's medical diagnoses of Dementia, Disorders of Bone Density and Structure, Hyperosmolality and Hypernatremia, Kidney Failure and Closed Fracture of Pubis. R87's Minimum Data Set (MDS) dated [DATE] documents R87 as severely cognitively impaired. R87's Nurse Progress Note dated 8/7/23 at 6:49 PM documents Ambulance service arrived and transported resident to emergency room. Facility is not able to provide documentation that State Ombudsman was notified of R87's transfer to emergency room due to fall with major injury. On 12/6/23 at 10:30 AM V6 Business Office Manager stated Normally I send the Ombudsman a list of residents who were sent to the hospital every month. I must have missed (R87). (R87) did go to the hospital in August 2023 and that notification should have been…

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 a Bed Hold Policy to three (R39, R63, R87) of four residents hospitalized in a sample list of 58 residents. Findings include: The undated facility policy titled 'Bed Hold Notification' documents when a resident is transferred to a hospital, or when the resident takes a therapeutic leave of absence, they have the right to request that their bed be held until their return. Such a request is called a bed-hold. The bed-hold notification will be issued at the time of transfer and in cases of emergency transfer, notice will be given within 24 hours of the leave. 1.) R39's Minimum Data Set (MDS) dated [DATE] documents R39 as severely cognitively impaired. R39's Nurse Progress Note dated 11/9/23 at 6:08 PM documents (R39) started to complain of her head hurting and her right side hurting. Ambulance arrived at 5:10 PM. (R39) left the facility at 5:15 PM via ambulance. R39's Electronic Medical Record (EMR) does not document a Bed Hold Policy being sent…

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 label a date opened on residents eye drops/ointments. This failure affects five residents (R33, R25, R66, R12, R9) reviewed for medication storage in the sample list of 58. Findings include: The facility's undated Storage of Medication policy documents, All discontinued/expired medications are to be removed from the active storage/medication use area. On 12/5/23 at 11:59, during the southwest medication cart review with V3 Licensed Practical Nurse there were eye drops without open dates on R66's Systane Balance Solution eye drops, R12's Timolol Maleate Solution 0.5% eye drops and Brimonidine Tartrate Solution 0.2% eye drops and R9's Muro 128 Solution eye drops all were opened and had no date documented on them of when they were opened. On 12/6/23 at 10:17 AM, during the North Memory Care medication cart review with V14 Registered Nurse there was R33's Vyzulta Solution 0.024% eye drops with an open date of 8/20/23 written on the box and there was R25's Refresh Lachrymal ointment with no open date on the box or…

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

Based on observation, interview, and record review the facility failed to maintain respiratory care tubing and masks in a clean sanitary manner for three residents (R260, R44, R9) of three residents reviewed for respiratory care in a sample list of 58 residents. Findings include: 1. R260's physician's orders sheet includes a physician's order dated 11/21/23 for CPAP (Continuous Positive Airway Pressure) at bedtime for sleep apnea. R260's Treatment Administration Sheet does not document a cleaning schedule or instructions for cleaning R260's mask and tubing. On 12/4/23 at 9:30AM, R260 stated The mask and tubing on my CPAP machine hasn't been cleaned since I came here. I guess I should have reminded them to do it. The mask and tubing were observed lying uncovered attached to the machine. There were crusty white areas on the mask and moisture in the tubing. On 12/6/23 at 12:00 PM, V2 Director of Nursing stated CPAP tubing and mask should be washed with soap and water daily and hung in a sanitary place to air dry.2. R9's Order Summary Report dated 12/6/23 documents diagnoses including…

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 the dignity of three (R5, R65, R71) of three residents reviewed for dignity in a sample list of 58 residents. Findings include: Facility pamphlet titled 'Illinois Long-Term Care Ombudsman Program Resident Rights' for people in Long-Term Care Facilities' revised 11/18 documents a resident has the right to make their own choices. The facility must treat the resident with dignity and respect. Facility Menu labeled Week two-Monday (12/4/23) documents ranch (barbecue sauce) meatloaf, garden blend rice, parslied cauliflower, garlic cheese biscuit and banana-peach cup as lunch meal. Facility Menu labeled Week two-Tuesday (12/5/23) documents taco salad, mexicali corn and frosted banana bread cake as lunch meal. 1.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 as severely cognitively impaired. This same MDS documents R5 requires moderate assistance with eating. R5's Care Plan intervention dated 3/11/22 documents Per therapy: It 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 complete a restraint assessment and obtain an order for a restraint prior to use for one of two residents (R56) reviewed for restraints in the sample list of 58. Findings Include: The facility's Restraint Program Policy and Procedure with a revised date of 11/10/15 documents, 1. Prior to the use of any restraint, (unless the restraint is used in an emergency situation) each resident is assessed for potential alternatives by using the restraint Pre-Restraining and Quarterly Evaluation UDA (User-Defined Assessments). 2. Documentation of alternatives are then listed in the resident's plan of care. 6. Reduction attempts are documented. Some examples of interventions may include, but are not limited to: a. Therapy consultation b. Environmental modifications c. Positioning d. Activity programming e. Toileting programming. R56's Order Summary Report dated 12/6/23 documents diagnoses including Unspecified Dementia, Muscle Weakness, Other Abnormalities of Gait and Mobility, Unsteadiness on Feet and Parkinson's Disease.…

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 report an injury of unknown origin to the state agency within two hours of discovering the injury for one of one (R68) resident reviewed for abuse on the sample list of 58. Findings include: On 12/6/23 at 10:00 AM, R68 was lying in bed. A quarter size blackish purple bruise was on R68's right jaw line. V12 Certified Nursing Assistant was present and stated the bruise has been there for a couple days and no one knows how it occurred. R68's nursing note dated 12/4/23 at 4:00 PM, documents a three centimeter by two centimeter bruise was observed on the right side of R68's face by chin/jawline. This note documents the Director of Nursing (V2) was notified. R68's medical record does not document that the state agency was notified of the R68's bruise. On 12/6/23 at 9:00 AM, V2 Director of Nursing stated the bruise was reported to him and V1 Administrator and they are considering it an injury of unknown origin and they are currently investigating the bruise. On 12/6/23 at 2:00 PM, V1 Administrator stated that they…

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 include the cleaning and maintenance of a Continuous Positive Airway Pressure (CPAP) machine on the Care Plan for one (R260) of 24 residents reviewed for Care plans in a sample list of 58. Findings include: R260's physician's orders sheet includes a physician's order dated 11/21/23 for CPAP at bedtime for sleep apnea. R260's Care Plan does not include resident centered interventions to maintain and clean R260's CPAP equipment. On 12/6/23 at 2:00 PM V16, Care Plan Coordinator stated (R260) should have a care plan in place for her CPAP.

Based on interview and record review the facility failed to update a resident's care plan with weight loss for one of 24 residents (R56) reviewed for care plans in the sample list of 58. Findings include: The facility's Care Plan Process policy with a revised date of November 2017 documents, All plans of care must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessment. 1.) R56's Order Summary Report dated 12/6/23 documents diagnoses including Gastro-Esophageal Reflux Disease, Dysphagia, Unspecified Dementia and Parkinson's Disease. This Order Summary documents a diet order of a regular pureed diet with moderately (honey) thick consistency liquids and High Pro ice cream two times a day for weight control. On 12/4/23 at 11:14 AM, V20 R56's Spouse stated that R56 has lost a lot of weight since R56 has been in the facility and R56 has been here for about a year. R56's medical record documents on 11/21/23 at 3:17 PM, by V21 Consultant Dietician, a noted significant weight loss of 7.9 % (percent) 12 pounds in…

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 restorative nursing services for ambulation following discharge from therapy services for one of one residents (R56) reviewed for range of motion in the sample list of 58. Findings include: R56's Order Summary Report dated 12/6/23 documents diagnoses including Unspecified Dementia, Muscle Weakness, Other Abnormalities of Gait and Mobility, Unsteadiness on Feet and Parkinson's Disease. On 12/4/23 at 11:14 AM, V20 R56's Spouse stated that they were doing leg exercises with R56 but that stopped all of a sudden and V20 does not know why. R56's Physical Therapy Discharge summary dated [DATE] and signed by V22 Physical Therapist documents Discharge Recommendations that R56 be placed on a Restorative program for ambulation and use of a recumbent bike. On 12/5/23 at 2:42 PM, V13 Restorative Certified Nursing Assistant stated that R56 was not on any restorative walking program. V13 stated that V9 Assistant Director of Nursing implements those. 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 provide behavioral health care and services for a resident having frequent crying episodes. This failure affects one of one (R66) residents reviewed for mood on the sample list of 58. Findings include: R66's Diagnosis list dated 10/18/21 documents R66 has a diagnosis of Recurrent Depressive Disorder. R66's Care plan dated 10/18/21 includes a care plan for Mood/Behaviors that documents that at times R66 may experience episodes of impaired moods/behaviors. This care plan includes interventions to, Assess me for signs that I might be harmful to myself or others. Ensure a safe and secure environment. Eliminate any potential hazards. Determine if these episodes are due to medications, sensory, psychosocial distress, environment, disease, losses, lack of control, pain, fear, uncertainty, changes or unmet needs. Monitor me for acute episodes of impaired mood such as sadness, loss of pleasure and interest in activities, feelings of sadness, guilt, change in appetite/eating habits, change in sleep patterns, diminished…

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 in accordance with Physician's Orders and manufacturer's recommendations for two of five residents (R65, R258) reviewed for medication administration in the sample list of 58. The facility had 2 medication errors out of 29 opportunities resulting in a 6.9% (percent) medication error rate. Findings include: The facility's Medication Administration policy dated 1/11/10 documents, It is the policy of this facility to accurately administer medication following physician's orders. Compare label with MAR (Medication Administration Record). 1.) R65's Order Summary Report document a diagnosis of Hypothyroidism. This Order Summary documents an order for Levothyroxine Sodium Oral Tablet 75 mcg (micrograms) by mouth in the morning for Hypothyroidism with a start date of 9/26/23. On 12/5/23 at 9:10 AM, V3 Licensed Practical Nurse (LPN) prepared R65's 8:00 AM medications. R65's Levothyroxine medication card documents to give Levothyroxine 75 mcg and to take on an empty stomach with a full glass 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 observation, interview and record review the facility failed to honor food preferences for two (R30, R35) out of two residents reviewed for food preferences in a sample list of 58 residents. Findings include: 1.) R30's Meal Ticket dated 12/4/23 Lunch Meal documents R30 dislikes Barbecue sauce. On 12/4/23 at 11:40 AM V12 [NAME] placed portion of ranch meatloaf covered in barbecue sauce onto R30's plate which was served to R30. On 12/4/23 at 12:45 PM R30 stated I would have liked my meatloaf without the barbecue sauce but no one asked me. On 12/4/23 at 1:40 PM V12 [NAME] stated V12 did not realize R30 disliked barbecue sauce. V12 verified R30's meal ticket had barbecue sauce listed as a dislike. 2.) R35's Meal Ticket dated 12/4/23 Lunch Meal documents R35 dislikes Barbecue sauce. On 12/5/23 at 11:40 AM, V12 [NAME] placed portion of ranch meatloaf covered in barbecue sauce onto R35's plate which was served to R35. On 12/4/23 at 11:45 AM, V12 [NAME] plated R35's lunch meal. V12 looked at R35's meal ticket…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately encode the Minimum Data Set Resident Assessment Instrument for falls experienced by a resident. This failure affects one resident (R3) out of four reviewed for falls on a sample of four. Findings include: R3's Nurses Notes dated 7/22/23 and 7/23/23 document R3 experienced falls in the facility on these two dates. R3's Nurses Notes on 7/22/23 document R3 was found on the floor with no apparent injury after an unwitnessed fall. R3's Nurses Notes dated 7/23/23 document R3 had experienced a fall and incurred a minor injury in the form of a skin tear to the right cheek which required adhesive strips applied at the facility. R3's Minimum Data Set (MDS) dated [DATE] documents in section J, R3 had experienced 0 (zero) falls since the previous admission or the previous Minimum Data Set. R3's most recent MDS dated [DATE] was for a re-admission from an acute care hospital which does not include section J. R3's next prior Minimum Data Set, dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete an initial, or subsequent, Abnormal Involuntary Movement Scale for a resident receiving antipsychotic medications. This failure affects one resident (R3) out of four reviewed for falls on a sample of four. Findings include: R3's Physician Order Sheet dated 10/31/23 documents R3 has current physician orders to receive the medication Zyprexa (antipsychotic) 2.5 milligrams every day at bedtime. This same Physician Order Sheet documents R3's Zyprexa order was initiated 7/26/23. R3's Assessments list dated 11/1/23 documents R3 received a psychotropic medication assessment on 7/19/23, prior to initiation of the Zyprexa which included an antidepressant medication (Sertraline) and an antianxiety medication (Lorazepam). There was not an initial psychotropic medication assessment dated on, nor around, the date of initiating R3's antipsychotic medication Zyprexa (7/26/23). R3's subsequent psychotropic medication assessment dated [DATE] only had the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to report and notify the Administrator and Director of Nursing about injuries of unknown origin for one resident (R1) of three residents reviewed for Injury of Unknown Origin in the sample of three. Findings include: R1's undated Face Sheet, documents R1's diagnoses as Unspecified Dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety; Age-related Osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing; Muscle weakness, and other abnormalities of gait and mobility; unsteadiness on feet. R1's Minimum Data Set (MDS) dated [DATE], documents R1 is severely cognitively impaired. R1's Care Plan dated 8/18/23, documents R1's safety awareness is compromised due to dementia and is at risk for falls related to unsteady gait, poor balance, weakness, unaware of safety needs; R1 is at risk for impaired skin integrity, osteoporosis, at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess bruising for one resident (R1) of three residents reviewed for resident injury in the sample list of three. Findings include: R1's undated Face Sheet, documents R1's diagnoses as: Unspecified Dementia, unspecified severity, without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; age-related Osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing; other specific Arthritis, unspecified site; Muscle Weakness, generalized; other abnormalities of Gait and Mobility; unsteadiness on feet; and pain in unspecified knee. R1's Minimum Data Set (MDS) dated [DATE], documents R1 is not cognitively intact. R1's Care Plan dated 4/7/23, documents R1's safety awareness is compromised due to Dementia and being at risk for falls related to unsteady gait, poor balance, weakness, and unaware of safety needs. R1's Nursing notes dated 8/9/2023 at 6:39 AM, document R1 has erythema,…

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.