Alden Terrace Of McHenry Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure gloves were changed when going from a dirty to a clean area to prevent cross contamination for 2 of 6 residents (R49 & R127) reviewed for infection control in the sample of 49.The findings include:1. On 4/14/26 at 1:02 PM, V12 (Certified Nursing Assistant-CNA) and V13 (CNA) were at R49's bedside to provide incontinence care. V12 and V13 had gloves on. V12 was incontinent of urine and a small amount of bowel movement. V12 unfastened R49's incontinence brief and pulled the front down. V12 took disposable wipes and cleaned one side of his groin, discarded the wipe and did the same procedure to the other side of his groin. V12 took a wipe and cleaned under his penis and scrotum area. V12 had bowel movement under the scrotum towards his anus that she wiped off and discarded the wipe. V12 did not change her gloves. V12 tucked the mechanical lift sling under the resident and placed a clean incontinence brief under him. V12 assisted R49…

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 ensure residents were treated in a dignified manner. This applies to 2 of 3 residents (R1 & R2) reviewed for dignity in the sample of 6. The findings include:On 4/4/26 at 9:31 AM, R1 stated, he was upset at V4 Certified Nursing Assistant (CNA). R1 stated that about a week ago, R1 was in the dining room and asked V4 to help a lady who is [AGE] years old who looked like she was pleading for help and can't speak English. V4 CNA refused to help him or the lady. R1 stated, he couldn't remember the resident's name but knows she lives on the 100 hall, is [AGE] years old, and speaks only Spanish. The facility's census showed a resident on the 100 hall that is [AGE] years old (R2). R1 confirmed that it was the resident, and he just needed to hear her name. He stated, V4 CNA is Spanish speaking as well and that is why he asked her to please help R2 because he couldn't understand what she was saying. V4 CNA told him 'no' and to ask the activity aide (V8) for help…

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 resident's guardian of a change in resident status for 1 of 4 residents (R1) reviewed for notification in the sample of 4.The findings include:R1's Face sheet shows R1 was admitted to the facility on [DATE]. This same Face sheet shows V5 is R1's Resident Representative State Guardian. R1's Nurses Note dated [DATE] at 1:54 AM shows, Resident expired, family and Hospice nurse present at bedside. On [DATE] at 3:54 AM the Nurses Notes show Resident's body picked up by funeral home. There is no further documentation in R1's progress notes regarding R1's death or that V5 was notified. On [DATE] at 10:41 AM, V4 (Licensed Practical Nurse) said when a resident expires the nurse notifies the physician, the resident's Power of Attorney and emergency contacts, and a guardian if the resident has one. V4 said if the resident were on hospice, they would need to be called also. V4 said the nurse on duty needs to chart in the progress notes the time of death…

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 ensure a resident was free from physical abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3.The findings include:A facility abuse investigation report dated 1/18/26 showed R2 was slapped in the face by R1 after R1 and R2 had a verbal altercation. R2 sustained a minor bloody nose because of the incident. R1 and R2 were separated by staff. R1 was sent to a local hospital for an evaluation. R1 was moved to a different unit, separate from R2, upon R1's return to the facility. The report showed both R1 and R2 had a diagnosis of dementia. R1's current care plan showed R1 was mildly cognitively impaired. R1 had a history of being verbally and physically abusive towards peers and staff. A progress note dated 5/16/25 showed R1 struck another resident with a television remote. A progress note dated 11/23/25 showed R1 pushed a CNA (certified nursing assistant). R2's current care plan showed R2 was severely cognitively impaired. On 1/26/26 at 9:00 AM, R1 stated he remembered the incident on 1/18/26 involving R2. R1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for transfers in the sample of 3.The findings include:R1's facility assessment dated [DATE] show R1 has a BIMS of 15-no cognitive impairment.The same assessment show R1 has no behavior of making false statements.R1's care plan (undated) documents R1 is at risk for falls due to diagnoses of multiple sclerosis (MS) with left sided weakness.R1 requires the use of mechanical lift for transfers, with intervention of: provide 2 staff assistance for transferring. On 12/18/25 at 9AM, R1 said the agency Certified Nursing Assistant -CNA came to the room last night and said it was time for your shower. R1 said he reminded V7 (CNA) that he needed another staff to help. V7 insisted he can do it himself. V7 said when he was strapped in the mechanical lift, and V7 was placing him in the shower chair, the shower chair moved, the shower chair tipped over with R1, both ending on the…

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

Based on interview and record review the facility failed to ensure a resident's representative was notified of a resident's change in condition to 1 of 3 residents (R1) reviewed for notification in the sample of 7.The findings include: R1's electronic face sheet under contacts documents V9 (R1's daughter) was: Resident Representative, emergency contact #1, care conference person, customer care representative V9's information included V9's address and phone number. On 9/26/25 at 10:10 AM, R1 was in bed with oxygen on at 2L via nasal cannula alert and able to verbalize her needs. R1 said she wanted her daughter to be informed of whatever was going on with her. R1 said she was hoping she will be able to speak to her soon, my daughter is the love of my life. R1's physician order sheet dated 8/17/25 documents Azithromycin Tablet 250 MG, give 2 tablets by mouth one time only for pneumonia, then Give 1 tablet by mouth in the afternoon for pneumonia for 4 Days.R1's medical record as confirmed with V2 (Director of Nursing) did not show that V9 R1's daughter and representative was informed 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 follow its policy for a resident that left the facility without supervision and staff knowledge for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 9.The findings include:Findings include:R1's Face sheet dated 8/16/25 showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to COPD (chronic obstructive pulmonary disease), moderate protein-calorie malnutrition, iron deficiency anemia, alcohol dependence, mood (affective) disorder, and hypertension.R1's Physician Order Sheet showed he was allowed to go out on a community pass alone.R1's Elopement Risk Assessment completed 7/17/25 showed he was not at risk for elopement.R1's facility assessment dated [DATE] showed he was cognitively intact and was independent with all Activities of Daily Living (ADLs).On 8/16/25 at 10:55 AM, V7 (Registered Nurse) said she was taking care of another resident when the door alarm went off. V7 said she immediately…

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 residents with coffee between meals per resident preferences. This applies to 4 of 4 residents (R31, R5, R110, R111) reviewed for choices in the sample of 50. The findings include: On 3/24/25 at 10:40 AM, R110 said a group of residents on the 500/600 units have had concerns about receiving coffee between meals per their preference. R110 said himself, R31, R5, R111, and a few others would get to the dining room early before meals, sit around tables together and converse or play games while drinking coffee. R110 said for a few months, the kitchen stopped bringing coffee up until just before meal time, resulting in these residents no longer getting together before meals. On 3/24/25 at 1:58 PM, R111 corroborated the concerns brought up by R110 that coffee is not served between meals when requested. On 3/25/25 at 9:15 AM, R31 said when the facility stopped serving coffee between meals, R31's family bought and provided R31 with a single serving coffee maker for in R31's room. R31 said the facility notified…

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 nutrional supplements were provided as ordered for residents with a history of a significant weight loss and failed to ensure weekly weights were obtained on a newly admitted resident. This applies to 4 of 4 residents (R18, R73, R140 and R148) reiviewed for nutrition in the sample of 50. The findings include: 1. R140's Face Sheet shows that she admitted to the facility on [DATE]. R140's Weights and Vitals Summary printed on 3/25/25 shows that R140 weighed 100 pounds (lbs) on 2/10/25. The summary shows that R140's weights as follows: 2/11-100 lbs, 2/12-100 lbs, 2/18-100 lbs, 3/5-95 lbs and 3/12-95.5 lbs. No additional weight were recorded. No weights were recorded for the week of 2/24/25. R140's Registered Dietitian Note dated 3/11/25 shows, Weight is 95 lb (5% loss x 1 mo (month), undesired, . below weight for age po (oral) intake variable aware of her weight, weight loss, agreeable to fortified pudding bid (twice a day) .discussed…

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 change gloves and perform hand hygiene in a manner to prevent cross contamination for four of six residents (R60, R85, R27, R62) reviewed for infection control in the sample of 50. The findings include: 1. R60's admission Record dated March 24, 2025 shows she was admitted to the facility on [DATE] with diagnoses including heart failure, vascular dementia, and history of falling. R60's Care Plan initiated June 8, 2019 shows she has an ADL self care performance deficit due to diagnoses of dementia. Interventions include assist with ADL care tasks as needed, assist with toileting needs as necessary. R60's Care Plan initiated August 23, 2019 shows R60 experiences frequent bladder incontinence due to diagnosis of dementia, check residents for incontinence. On March 24, 2025 at 10:17 AM, V9 CNA (Certified Nursing Assistant) went into R60's room to perform incontinence care to R60. R60 was laying in her bed. V9 folded R60 incontinence brief from…

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 privacy during personal care for two of two residents (R60, R85) reviewed for privacy in the sample of 50. The findings include: 1. R60's admission Record dated March 24, 2025 shows she was admitted to the facility on [DATE] with diagnoses including heart failure, vascular dementia, and history of falling. On March 24, 2025 at 10:17 AM, V9 CNA (Certified Nursing Assistant) provided personal care for R60. R60 was laying on her back in her bed. R60 had two roommates. One of R60's roommates was sitting in her wheelchair facing R60's bed. The privacy curtain was half pulled. V9 performed incontinence care to R60 exposing R60's front peri area. R60's private areas were visible to R60's roommate and R60's roommate glanced over at V9 and R60 multiple times. On March 25, 2025 at 9:28 AM, V13 (R60's daughter/power of attorney) said, I would hope that they are keeping it private when they are changing [R60's] incontinence brief or cleaning…

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 keep a resident free from physical abuse. This applies to 4 of 31 residents (R32, R92, R105, R80) reviewed for abuse in the sample of 50. The findings include: R32, R92, R105 & R80 all reside in a locked memory care unit. 1. R32's face sheet lists her diagnoses to include: dementia, delirium, mood disorder & unspecified psychosis not due to a substance or known physiological condition. On March 24, 2025 at 11:05 AM, R32 was upset and yelling. I had a slice of cabbage for supper, it's bullsh*t, call the police! I want a walker and a decent meal! On March 25, 2025 at 10:04 AM, R32 was upset and yelling in the dining room. I want a cup of coffee and want the hell out of here now! I want these people out, this is my house! R32's progress notes dated January 19, 2025 shows, Overheard another resident telling R32 That isn't your coffee and this RN (Registered Nurse) observed her trying to take someone else's coffee and then hit his arm while I was on the way to intervene . The facility did not provide an abuse…

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

Based on interview and record review the facility failed to follow it's own abuse policy. This applies to 4 of 31 residents (R32, R92, R105, R80) reviewed for abuse in the sample of 50. The findings include: On December 22, 2025, R32's progress notes show R32 hit R105. On January 16, 2025, R105's progress notes show R105 had a physical altercation with R80. On January 19, 2025, R32's progress notes show R32 hit R92. The facility did not provide an abuse investigation, incident report or any other documentation regarding any of the incidents. On March 26, 2025 at 1:38 PM, V1 (Administrator) stated, he didn't have any abuse investigations for the past four months. The facility's abuse policy dated September 2020 shows, Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive 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 interview and record review the facility failed to ensure staff identified and reported allegations of physical abuse to the administrator. This applies to 4 of 31 residents (R32, R92, R105 R80) reviewed for abuse reporting in the sample of 50. The findings include: On December 22, 2025, R32's progress notes show R32 hit R105. On January 16, 2025, R105's progress notes show R105 had a physical altercation with R80. On January 19, 2025, R32's progress notes show R32 hit R92. The facility did not provide an abuse investigation, incident report or any other documentation regarding any of the incidents. On March 26, 2025 at 12:44 PM, V4 Registered Nurse (RN) stated, she wasn't sure if she reported the incidents or not (December 22, 2024 and January 19, 2025). On March 26, 2025 at 1:18 PM, V18 Licensed Practical Nurse (LPN) stated, she did report the incident to both V1 (Administrator) and V2 (Director of Nursing). On March 26, 2025 at 1:38 PM, V1 (Administrator) stated, he did not have any abuse investigations for the past four months. Sometimes what they see and what 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 investigate allegations of physical abuse. This applies to 4 of 31 residents (R32, R92, R105, R80) reviewed for abuse investgations in the sample of 50. The findings include: On December 22, 2025, R32's progress notes show R32 hit R105. On January 16, 2025, R105's progress notes show R105 had a physical altercation with R80. On January 19, 2025, R32's progress notes show R32 hit R92. The facility did not provide an abuse investigation, incident report or any other documentation regarding any of the incidents. On March 26, 2025 at 1:38 PM, V1 (Administrator) stated, he did not have any abuse investigations for the past four months. Sometimes what they see and what they document isn't always the same. On March 27, 2025 at 10:22 AM, V1 (Administrator) clarified, the incidents were reported to him as behaviors and not as a physical exchange therefore he did not take them as abuse allegations.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for one of three residents (R60) that are dependent on staff for ADL care in the sample of 50. The findings include: R60's admission Record dated March 24, 2025 shows she was admitted to the facility on [DATE] with diagnoses including heart failure, vascular dementia, and history of falling. R60's Care Plan initiated June 8, 2019 shows she has an ADL self care performance deficit due to diagnoses of dementia. Interventions include assist with ADL care tasks as needed, assist with toileting needs as necessary. R60's Care Plan initiated August 23, 2019 shows R60 experiences frequent bladder incontinence due to diagnosis of dementia, Check residents for incontinence. On March 24, 2025 at 10:17 AM, V9 CNA (Certified Nursing Assistant) provided incontinence care to R60. V9 removed R60's incontinence brief. R60's incontinence brief was saturated with dark urine and had some stool in it. 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 ensure residents received treatments, care, and services in accordance with professional standards for 3 of 31 residents (R91, R88, R62) reviewed for quality of care in the sample of 50. The findings include: 1. On 3/25/25 at 8:57 AM, R91 said he had been having loose stools for approximately 9 days. On 3/26/25 at 11:02 AM, V2 (Director of Nursing) said R91 had been seen by the physician the week prior and again on 3/26/25. On 3/26/25 at 10:52 AM, V22 (Registered Nurse/RN) said R91 has been having some loose stools and R91 received an order for loperamide (a medication to help with loose stools). R91's physician progress note dated 3/18/25 performed by V27 (Nurse Practitioner) states resident had complaints of diarrhea for a few days. V27 recommended to give R91 loperamide as needed for relief and to also hold R91's stool softener. R91's Order Summary Report dated 3/25/25 shows an order for Loperamide HCl (Hydrochloride) with a start 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.

Based on observation, interview, and record review the facility failed to ensure pressure reducing interventions were in place for a resident at risk for pressure for 1 of 3 residents (R108) reviewed for pressure in the sample of 50. The findings include: On 3/24/25 at 9:48 AM, R108 was in bed with a pillow under her right side. R108's heels were flat on the bed. On 3/25/25 at 10:14 AM, V6 (Wound Nurse) said R108 has a stage 4 pressure injury to her sacrum that was first found on 1/10/24. V6 said R108 has pressure reducing interventions in place such as a low air loss mattress, dietary supplements, and frequent turning and repositioning. V6 said R108 does not have an order for padded heel boots. V6 said the facility follows orders for treatment and interventions from the Wound Doctor. On 3/25/25 at 12:30 PM, R108 was flat on her back in bed sleeping. R108's heels were flat on the mattress, not offloaded with pillows or heel boots. R108's Wound Doctor Progress Noted dated 3/18/25 shows R108 has a stage 4 pressure injury to her sacrum and shows Plan of Care- Avoid bony prominences…

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 monitor and implement interventions for a resident with a contracture for 1 of 1 residents (R42) reviewed for contractures in the sample of 50. The findings include: On 3/24/25 at 10:01 AM, R42 was in bed waiting for breakfast. R42's left hand was contracted with her fingers flat on the palm of her hand. R42 said her hand is contracted from a stroke. R42 used her right hand and was able to straiten her fingers out some (formed a C with her hand). R42 said they sometimes put a washcloth in her palm but only when she asks. V17 (Certified Nursing Assistant) came in to answer R42's call light and said she was not aware of any splint or brace for R42's hand. On 3/25/25 at 12:30 PM, R42 was up in her wheelchair at the bedside waiting for lunch. R42's fingers on her left hand were contracted and flat on the palm of her hand. On 3/25/25 at 2:11 PM, V15 (Restorative Licensed Practical Nurse) said R42 was seen by therapy some time ago with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On March 24, 2025 at the noon meal, R105 was sitting up in her wheelchair in the dining room eating lunch. Her wheelchair did not have anti-tippers on it. On March 25, 2025 at 10:04 AM, R105 was sitting up in her wheelchair in the dining room doing activities. Her wheelchair did not have anti-tippers on it. R105's incident report dated January 22, 2025 shows, Resident was in the dining room. This writer and the other NOD (nurse on duty) suddenly heard a loud sound then found the resident on the floor holding the back of her head On March 25, 2025 at 1:34 PM, V21 (Registered Nurse) stated, she was the nurse working when R105 fell on January 22, 2025. R105 tipped her wheelchair backwards and hit her head on the floor. She is supposed to have anti-tippers on her wheelchair. She confirmed that R105's wheelchair did not have anti-tippers on it and should. R105's care plan (no date) shows, Focus: R105 is at risk for falls due to dx (diagnosis) of history of falls. Interventions: anti-tip to wheelchair . Based 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 maintain an urinary drainage bag below the level of a resident's bladder for one of one resident (R85) reviewed for catheters in the sample of 50. The findings include: R85's admission Records dated March 25, 2025 shows she was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, neuromuscular dysfunction of bladder, bipolar disorder, anxiety disorder, urinary retention, and history of falling. R85's Care Plan intitiated on December 6, 2023 shows, [R85] requires the use of an indwelling catheter. Catheter care per orders and position the collection bag below the level of the bladder. On March 24, 2025 at 10:38 AM, R85 was in bed laying on her back. R85 had a urinary drainage device. There was amber colored urine in the tubing of R85's urinary drainage device. V9 CNA and V10 CNA (Certified Nursing Assistants) prepared R85 to get out of bed via mechanical lift. V9 lifted R85's urinary drainage bag above the level…

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 records review the facility failed to implement interventions to an excoriated gastrostomy tube (G-tube) for 1 of 2 residents (R2) reviewed for G-tubes in the sample of 50. The findings include: On 3/24/25 at 10:39 AM, R2 was in bed with a tube feeding pump connected to her G-tube. V17 (Certified Nursing Assistant) lifted R2's gown to show this surveyor R2's G-tube site on her abdomen. R2 did not have a dressing around the entrance of the G-tube. There was noticeable red excoriation on R2's skin around the bottom of the G-tube extending out approximately 1.5 inches in width and 2.5 inches in length. V17 said she would let the nurse know about the redness. On 3/25/25 at 10:17 AM, V6 (Wound Nurse) said the nurse had him look at R2's G-tube site yesterday. V6 said R2 had some red excoriation around the site and he got an order for zinc oxide and a drain sponge dressing. V6 said he was not aware of any skin issues to R2's site prior to yesterday. On 3/25/25 at 1:54 PM, V16 Registered Nurse (RN) said is a skin issue is found the nurse makes a skin…

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 ensure medications were ordered before running out resulting in a missed medication administration. This applies to 1 of 31 residents (R5) reviewed for medications in the sample of 50. The findings include: R5's Facesheet dated 3/26/25 shows R5 has diagnoses that include, but are not limited to, diabetes mellitus type two, systolic (congestive) heart failure, hypertensive heart disease with heart failure, and cardiomyopathy. On 3/26/25 at 12:08 PM, R5 said R5 receives an expensive heart medication for R5's diagnoses of heart failure and heart disease. R5 said there were a few occasions that the facility did not have the medication on hand and R5 missed doses of the heart medication. R5's Order Summary Report dated 3/26/25 shows R5 receives Sacubitril-Valsartan for hypertensive heart disease with heart failure with a start date of 9/9/24. R5's December 2024 Medication Administration Record (MAR) shows R5 did not receive the 9:00 PM dose for Sacubitril-Valsartan on 12/8/24. R5's Orders Note for eMAR (electronic MAR) 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 ensure R30 and R97 received their medication on time for 2 of 4 residents reviewed for medication errors in the sample of 50. The findings include: The facility CMS-671 exit date 3/26/25 shows, a Medication Error Rate of 6.67 percent. On 03/24/25 at 10:01AM, V5 (Registered Nurse) was at the 400 Hall medication cart. Five residents were displayed on the EMAR-Electronic Medication Administration Record including R97 and R30 with a red background. V5 RN closed the computer and locked the medication cart. On 03/24/25 at 10:01 AM, V5 RN said, the medications are late. I will call the residents' doctors to let them know. On 03/24/25 at 10:07AM, V5 RN returned to the medication cart and said, the doctors gave me permission to pass the medications late. 1. R97's EMAR dated March 2025 shows, multiple diagnoses including psychosis, psychotic disturbances. On 03/24/25 at 10:07AM, V5 RN provided R97 with her 9:00AM, Physician Ordered medications: quetiapine 50mg (milligrams) by mouth, sertraline 50mg by mouth, and 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.

Based on observation, interview, and record review the facility failed to ensure dietary preferences were served for 2 of 3 residents (R142, R91) reviewed for preferences in the sample of 50. The findings include: 1. On 03/24/25 at 10:54 AM, R142 was in his room sitting at the bedside. R142 said he has a tube feeding and he can eat, but they serve him puree and he doesn't want it. R142 said there are a few things that he likes to eat and he had told them but they rarely bring them. R142 said he likes soup and apple juice. On 03/24/25 at 12:20 PM in the 400 hall dining room dietary staff was filling resident meal trays. R142's dietary ticket showed puree, general, thin liquid. SEND EVERY MEAL PER PREFERENCE soup broth or creamy soup (such as tomato soup), apple juice, ice cream, pudding and oatmeal. Standing orders: 4 fluid ounce Apple Juice 3.25 fluid ounce Assorted Pudding- Any flavor 6 fluid ounce Chicken Broth 1/2 cup Ice Cream-any flavor. On 03/24/25 at 12:35 PM, R142's tray was delivered to his room. There was no soup, ice cream, pudding, or apple juice observed. R142 was…

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

Based on observation and interview, the facility failed to provide a clean, sanitary, and odor free environment for 1 of 1 resident (R99) reviewed for safe/clean/comfortable/homelike environment in the sample of 32 and 3 residents (R7, R97, R120) outside of the sample. The findings include: 1) On 5/14/24 at 10:19AM, R7's fitted bed sheet had 2 large yellow stains on it. R7's room had a strong urine odor present. On 5/15/24 at 9:37AM, R7's fitted bed sheets had the same 2 yellow stains and room odor that were present on 5/14/24. On 5/15/24 at 12:18PM, R7's fitted bed sheet had the same 2 yellow stains and additional brown stains present on them. R7's pillowcase had 2 brown stains on them that appeared to be from coffee. On 5/16/24 at 8:45AM, R7's fitted bed sheet and pillowcase had the same stains that were present on 5/14/24 and 5/15/24. R7 was not interviewable. 2) On 5/14/24 at 10:10AM, R97's fitted bed sheet had 2 large smears of brown and 1 large yellow stain. On 5/15/24 at 9:42AM, R97's fitted bed sheet had the same stains present as 5/14/24. On 5/16/24 at 8:48AM, R97's fitted…

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 perform a safe transfer for 1 resident (R74), failed to perform safe smoking assessments for 2 residents (R53, R125) and failed to intervene when a resident was tipping his wheelchair for 1 resident (R17). These failures apply to 4 of 4 residents reviewed for safety/supervision in the sample of 32. The findings include: 1) R17's electronic face sheet printed on 5/16/24 showed R17 has diagnoses including but not limited to atrial fibrillation, Alzheimer's disease, dementia with agitation, anemia, polyneuropathy, heart failure, atherosclerotic heart disease, pacemaker, hypertension, and bradycardia. R17's facility assessment dated [DATE] showed R17 has severe cognitive impairment. On 5/14/24 at 12:15PM, R17 was sitting at the dining table with both of his wheels locked on his wheelchair. R17 was pushing back from the table and tipping his wheelchair backwards. R17 was agitated and yelling at other residents at his table. Multiple facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's request for Advance Directives regarding Cardiopulmonary Resuscitation (CPR) was accurately incorporated into the medical record for 1 of 1 resident (R28) reviewed for advance directives in the sample of 32. The findings include: R28's face sheet printed on [DATE] showed an admission date of [DATE]. On [DATE], R28's eMAR (electronic medical record) was reviewed. The computer banner screen showed the code status as full code and DNR (Do Not Resuscitate). R28's [DATE] physician order tab showed an order dated [DATE] for: Code status: Attempt resuscitation/CPR (full code) The same tab showed a second order dated [DATE] for: Code status: Do not attempt resuscitation (DNR). R28's POLST (Practitioner Order for Life-Sustaining Treatment) was dated [DATE] and showed No CPR: Do not attempt Resuscitation. R28's care plan showed a focus area related to code status. R28 was documented as a full code and wishes to remain a full code. On [DATE] at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide bathing assistance for 1 resident (R99), and failed to provide meal set-up and transfer assistance for 1 resident (R335). These failures apply to 2 of 5 residents reviewed for activities of daily living in the sample of 32. The findings include: 1) R99's electronic face sheet printed on 5/16/24 showed R99 has diagnoses including but not limited to dementia without behaviors, hypotension, muscle weakness, and wedge compression fracture of T11-T12 vertebra. R99's facility assessment dated [DATE] showed R99 has severe cognitive impairment, requires substantial assistance for bathing, and has no behaviors of rejecting care. R99's nursing progress notes for April 2024 and May 2024 showed no documentation related to R9 refusing showers. R99's care plan dated 11/14/22 showed, (R99) has an ADL (activities of daily living) self-care performance deficit due to diagnosis of dementia, muscle weakness, hypertension, malnutrition, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to complete dressing changes for (R53) and failed to have preventative measures in place for a resident (R74) with non-pressure wounds for 2 of 6 residents reviewed quality of care in the sample of 32. The findings include: 1. On 5/15/24 at 10:20 AM, R53 was self-propelling his wheelchair in the hallway, near his room. R53 had a left above the knee amputation. R53 was wearing a black tennis shoe on his right foot with a gauze dressing noted extending from the shoe. The skin on R53's right ankle and lower shin was red and shiny. R53 said he had an infection in his leg and probably will have to have more toes cut off. R53 said he's been dealing with the wounds for a long time. R53 said the dressing to his right foot is only changed every couple of days. R53's Facesheet dated 5/16/24 showed diagnoses to include, but not limited to: amputation surgical aftercare, left above the knee amputation, PVD (peripheral vascular disease), Stage 3 CKD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's heels were offloaded for 1 of 7 residents (R30) reviewed for pressure ulcers in the sample of 32. The findings include: R30's admission Record, printed by the facility on 5/16/24, showed she had diagnoses including Alzheimer's disease, aphasia (a language disorder that affects a person's ability to understand and express language, reading, and writing), anxiety disorder, and psychotic disorder with hallucinations due to known physiological condition. R30's facility assessment dated [DATE] showed she is dependent on staff for toileting, bathing, upper and lower body dressing, bed mobility, and personal hygiene. The assessment showed R30 had an unstageable, deep tissue pressure injury. R30's care plan initiated on 4/8/2021 showed she had a deep tissue injury to her right heel. The care plan showed R30 had a history of pressure injuries to her left heel and sacral area. On 5/16/24 at 9:43 AM, R30 was sitting in her…

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

Based on observations, interview and record review the facility failed to ensure a urinary catheter bag did not come in contact with the floor, failed to ensure the catheter bag was not above the level of the bladder, and failed to ensure a urinary catheter bag was emptied before urine backed up past the tubing. This applies to 2 of 5 residents (R74, R92) reviewed for catheter care in the sample of 32. The findings include: 1. R92's Face Sheet shows his diagnoses to include: stage 3 chronic kidney disease, obstructive and reflux uropathy, nodular prostate with lower urinary tract symptoms, and retention of urine. On 5/14/24 at 12:00 PM, R92 was in bed with his urinary catheter bag hanging on the side of his bed. The catheter bag was full to the top but not yet into the tubing. On 05/15/24 at 1:19 PM, R92 said, the CNA's (Certified Nursing Assistant) didn't dump the urine bag yesterday in time before it came all the way up the tube and backed up past the catheter. I pressed the call light because I felt bladder pressure, and finally a CNA dumped it. On 05/15/24 at 12:15 PM, R92 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to intervene for a resident experiencing behaviors for 1 of 1 resident reviewed for dementia care in the sample of 32. The findings include: R17's electronic face sheet printed on 5/16/24 showed R17 has diagnoses including but not limited to atrial fibrillation, Alzheimer's disease, dementia with agitation, anemia, polyneuropathy, heart failure, atherosclerotic heart disease, pacemaker, hypertension, and bradycardia. R17's facility assessment dated [DATE] showed R17 has severe cognitive impairment and experiences physical and verbal behaviors. R17's nursing care plan dated 3/15/24 showed, Resident has the potential for/history of physical aggression towards others. Poor impulse control. Complete behavior tracking when behavior occurs. Observe resident behavior/interactions around other residents and monitor for aggressive behaviors. Remove resident from any potential situation which could precipitate aggressive behavior. On 5/14/24 at…

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

Based on observation, interview, and record review the facility failed to administer medications as ordered by not documenting a medication was given and not administering a medication at the scheduled time. There were 25 opportunities with 2 errors resulting in an 8% error rate. This applies to 1 of 6 residents (R47) observed in the medication pass. The findings include: R47's face sheet printed on 5/16/24 showed diagnoses including but not limited to heart failure, diabetes mellitus, irritable bowel syndrome, diverticulosis, and hypertension. R47's May 2024 physician orders showed an order for one docusate sodium oral capsule 100 milligram to be given every 24 hours for bowel management. The order showed one losartan potassium oral tablet 50 milligrams to be given one time a day for hypertension. On 5/15/24 at 8:35 AM, V14 (RN-Registered Nurse) administered R47's scheduled 9 AM medications. V14 gave a total of 9 pills which included one docusate capsule. V14 did not dispense or give the losartan potassium tablet. At 11:21 AM, R47's medication administration report (MAR) was…

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

Based on observation, interview, and record review the facility failed to label and store medications according to their policy for 2 of 4 medication carts reviewed for medication storage. The findings include: On 5/15/24 at 9:53 AM, the 100-hall medication cart was reviewed with V20 (RN-Registered Nurse) present. The top drawer of the cart had three medication cups filled with pills. One cup held nine greenish-black tablets, one held four tan tablets, and one held four red capsules. All three cups were unlabeled. V20 said she guessed the pills were iron, a laxative, and multivitamins but was for sure. V20 stated she did not realize they were in the cart and was not sure where they came from. V20 said she had no idea who the pills belonged to or why they were not in the proper containers. V20 said there is the potential for administration mistakes, and they should not be in the cart without labeling. On 5/15/24 at 10:26 AM, the memory cart unit medication cart was reviewed with V19 (Licensed Practical Nurse) present. The top drawer of the cart had four prepackaged medications laying…

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 incontinent care in a manner to prevent infection, failed to wash a resident's hands after they were contaminated during care, and failed to wear the appropriate personal protective equipment (PPE) while providing direct care for a resident on enhanced barrier precautions for 2 of 2 residents (R30, R22) reviewed for infection control in the sample of 32. The findings include: 1. R30's admission Record, printed by the facility on 5/16/24, showed she had diagnoses including Alzheimer's disease, aphasia (a language disorder that affects a person's ability to understand and express language, reading, and writing), incontinence without sensory awareness, diaper dermatitis, anxiety disorder, and psychotic disorder with hallucinations due to known physiological condition. R30's facility assessment dated [DATE] showed she is dependent on staff for toileting, bathing, upper and lower body dressing, bed mobility, and personal hygiene. 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 ensure the prescribed treatment orders were implemented and changed daily for a resident with wound ulcers. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 3. The findings include: R1's face sheet shows he is [AGE] year-old male admitted to the facility on [DATE]. R1's diagnoses include cerebral infarction, anemia, rheumatoid arthritis with rheumatoid factor of left hand, unspecified dementia, unspecified osteoarthritis, and bipolar. R1's Wound Physician Progress note dated 1/17/24 documents non-pressure chronic ulcer to left lower leg with fat exposed measuring 15 cm (centimeter) x 10 cm x 01.cm. A new ulcer identified to the right thigh measuring 13 cm x 5 cm x 0.1 cm. The treatment orders for the left lower leg/knee and right thigh include to cleanse with normal saline apply topical gentamycin ointment, cover with adpatic, abdominal pad (abd), and kerlix. R1's Treatment Administration Record for January shows…

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 R1's wound care doctor's treatment recommendations for one of five residents (R1) reviewed for wound care in the sample of five. The findings include: On 11/01/23 R1 was not in the facility. On 11/01/23 at 11:30 AM, V5 Wound Care Nurse said, R1was sent to the hospital on [DATE] due to a change in the color of his left toe. R1 was seen on 04/05/23 by V4 Wound Doctor/Extender for a stage three pressure ulcer on his left heel and made recommendations. Specialist appointments are made by V6 Appointment Maker. On 11/01/23 at 1:30 PM, V4 Wound Doctor/Extender said, I saw R1 on April 5, 2023, for a left heel Stage 3 pressure ulcer. The dopplar circulation assessment found obstruction in the arteries and veins in the legs. Test results would show 1.0 as normal and 0.9 or less is an occlusion (reduced circulation). R1's results were 0.6 and 0.7, there is a slow rate of blood flow. R1 has PVD-Peripheral Vascular Disease and needs to 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.