Ignite Medical McHenry

Based on observation, interview, and record review, the facility failed to ensure residents were changed in a timely manner for 1 of 5 residents (R5) reviewed for ADLs (activities of daily living) in the sample of 7.The findings include:On 8/11/25 at 10:22 AM, R5 was lying in bed in her room. A strong, foul odor was immediately noted upon entering R5's room. V6 and V7, Certified Nursing Assistants (CNAs) were in R5's room to change her. R5's brief, pad, and sheet were all saturated through to the mattress with dark, foul-smelling urine.On 8/11/25 at 10:39 AM, R5 said no one changed her earlier.On 8/11/25 at 1044 AM, V7 said she did not change or help change R5 earlier today and she doesn't know when R5 was last changed as V4 was R5's CNA.On 8/11/25 at 12:33 PM, V4 said R5 is her resident today and she and V6 changed R5 at about 7:30 AM today. V4 said residents should be changed every two hours.On 8/11/25 at 1:01 PM, V2, Director of Nursing/Chief Nursing Officer, said incontinent residents are supposed to be changed every two hours and as frequently as needed. V2 said staff are to…

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 notification when R1's psychiatric medication was discontinued for 1 of 9 residents reviewed for notification in the sample of 9.On 08/06/2025 R1 was not in the facility.R1's MDS-Minimum Data Set, dated [DATE] shows, R1's Brief Interview for Mental Status shows, moderately impaired.R1 has multiple diagnoses including, ADHD-Attention Deficit Hyperactivity Disorder, traumatic brain injury, dementia.On 08/06/2025 at 9:30AM, V6 R1's Husband said, a few years ago R1 had a cardiac event and lost consciousness. As she fell, she hit the front part of her head; we lost a large part of who she was. R1 has a diagnosis of ADHD. I do not know why the facility did not notify me of this change in treatment. R1 currently lives in Assisted Living with me. It allows me to care for her and prepare our house for sell. I contacted R1's psychiatrist. The psychiatrist said the treatment should not have been stopped. I would think the facility's physician…

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 R1 and R2 had a Physicians Order for the use of a CPAP-Continuous Positive Airway Pressure machine for 2 of 3 resident (R1,R2) reviewed for Respiratory Services in the sample of 9. 1.On 08/06/2025 at 10:18AM, R2 was lying in bed. R2's CPAP-Continuous Positive Airway Pressure device was on the bedside.On 08/06/2025 at 10:18AM, R2 said, my family set up the CPAP machine for me. The facility keeps the machine filled with distilled water. I put it on myself.R2's Physician's order dated 07/11/25 shows, Respiratory Therapy evaluate and treat if indicated.On 08/07/2025 at 3:00PM, V5 RT-Respiratory Therapy said, R1, R2, and R3 all use their home CPAP machines. As respiratory therapy we do not do anything with the resident's home machine. The Nursing staff contacts the physician for an order for the CPAP; the physician's order also contains the prescribed settings needed for the machine to operate correctly.R2's Physician's Orders on 08/06/2025 shows, R2 did not have an order for a CPAP machine.2.On 08/06/2025…

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 observation, interview, and record review the facility failed to ensure consents for administration were obtained prior to administering anti-psychotic and anti-anxiety medications. This applies to 1 of 4 residents (R2) reviewed for psychotropic medications in the sample of 6. The findings include: R2's Census Report shows R1 originally admitted to the facility on [DATE] and left the faciity on 5/4/25 for a hospital stay. R2 returned to the facility on 5/11/25. R2's Hospital Discharge Paperwork dated 5/1/25 shows R2 was ordered to take escitalopram oxalate 20 milligrams (mg) one tablet daily and trazodone 50 mg one tablet nightly as needed. R2 was not ordered to take quetiapine while at the hospital or upon discharge from the hospital. On 6/2/25 at 12:15 PM, V8 (R2's Family Member) could not recall the facility providing V8 with a consent form to sign to provide V8 with quetiapine. V8 said V11 (R2's Son) and R2 were also both unaware of receiving a consent form to be administered quetiapine. V8 said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement fall interventions into the care plan after a fall for a resident at risk for falls, for 1 of 3 residents (R1) reviewed for safety in the sample of 7. The findings include: R1's Face Sheet shows she was admitted to the facility 3/25/24 and discharged [DATE]. R1's admitting diagnoses included muscle weakness, unsteadiness on her feet, reduced mobility, cellulitis of the left upper limb, end stage renal disease, and need for assistance with personal cares. R1's admitting Fall Risk Evaluation shows she scored a score of 12 which indicated she is a high fall risk. An Un-witnessed fall incident report dated 4/10/24 shows R1 had a fall that day in her room. She was found lying on the floor between her bed and her wheelchair. A second Witnessed fall incident report dated 4/22/24 shows R1 had another fall on 4/22/24 while transferring into bed, she slid off the bed and onto the floor. R1's Fall Risk Care Plan shows it was initiated on 3/25/24 (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 ensure staff followed physician orders for pressure injuries. This applies to 2 of 4 residents reviewed for pressure injures in the sample of 4. The findings include: 1. R2's electronic medical records (EMR) lists his diagnoses to include: displaced intertrochanteric fracture of right femur, muscle weakness and need for assistance with personal care. On February 20, 2025 at 12:05 PM, V3 wound care nurse (WCN) was changing R2's sacral dressing. R2's sacral dressing was dated February 16, 2025 and there was stool on the bottom portion of the dressing. Once the dressing was removed there was an open wound on both buttocks. The right side was approximately a quarter size open area. The left side was an elongated quarter size open area. Both wound areas were red and pink. The right side had some purplish tissue inside the wound. R2 stated, he fell and broke his hip which resulted in him laying in the bed too much. He stated, the dressings have…

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 midline catheter dressing was changed according to standard of practice for 1 of 3 residents (R2) reviewed for venous catheters in the sample of 3. The findings include: On 1/13/25 at 9:34 AM, R2 was sitting at the bedside and had a midline line catheter (a type intravenous (IV) line for administering IV medications) in his right arm. R2's midline line had a gauze like dressing at the insertion site of the line underneath a transparent bandage. The gauze was visibly and completely saturated with dried blood. R2's midline line dressing was dated 1/9/25. R2 said the hospital put the line in the day he was discharged to the facility so he could get antibiotics. On 1/13/25 at 11:50 AM, V4 Registered Nurse (RN) said PICC (Peripherally Inserted Central Catheter - a type of IV line for administering IV medications) or midline dressings are changed every 7 days or as needed and there is an order that comes up in the Medication…

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 ADL (Activities of Daily Living) assistance for a resident that requires assistance and failed to replace a soiled blanket for one of three residents (R4) reviewed for ADL assistance in the sample of four. The findings include: R4's admission Record dated October 15, 2024 shows she was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, peripheral vascular disease, diabetes mellitus, asthma, major depressive disorder, obesity, osteomyelitis, and heart failure. R4's Care Plan initiated May 12, 2021 shows she has an ADL self care performance deficit and limited physical mobility related to limited mobility and pain. R4 requires one staff member for personal hygiene and dressing. R4 requires the assistance of two staff members for bed mobility and toileting. On May 15, 2024 at 10:50 AM, V3 CNA (Certified Nursing Assistant) provided incontinence care for R4. V3 checked R4's incontinence brief and said,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have pressure injury prevention interventions in place and failed to change a soiled pressure injury dressing for two of three residents (R2, R4) reviewed for pressure injuries in the sample of four. The findings include: 1. R2's admission Record dated October 15, 2024 shows R2 was admitted tot he facility on August 23, 2024 with diagnoses including wedge compression fracture of first lumbar vertebra, paraplegia, diabetes, spinal stenosis, osteoarthritis, depression, and dysphagia. R2's Care Plan shows she was admitted to the facility with a stage four pressure injury to her sacrum and provide skin/wound treatments as ordered. R2's Order Summary Report dated October 15, 2024 shows sacrum cleanse with normal saline, apply moistened gauze to wound bed. Secure with foam until resolved. Every day shift every Monday, Wednesday, and Friday. It also shows an as needed order. R2's Risk Profile dated September 20, 2024 shows she is at high 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 observation, interview, and record review, the facility failed to wear PPE (Personal Protective Equipment) for residents on enhanced barrier precautions (EBP) and failed to change their gloves and perform hand hygiene in a manner to prevent cross contamination for three of four residents (R2, R3, R4) reviewed for infection control in the sample of four. The findings include: 1. R2's admission Record dated October 15, 2024 shows R2 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture of first lumbar vertebra, paraplegia, diabetes, spinal stenosis, osteoarthritis, depression, and dysphagia. R2's Care Plan shows she was admitted to the facility with a stage four pressure injury to her sacrum. On October 15, 2024 at 9:49 AM, R2 was observed in her bed. There was a contact isolation sign on R2's door. V3 CNA (Certified Nursing Assistant) said that R2 is on isolation for MRSA in her wound. At 10:33 AM, V3 provided incontinence care to R2. V3 wiped R2's front peri area,…

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 refrigerated foods were properly stored and labeled and failed to ensure hairnets were in place. This affects all residents residing in the facility. The findings include: The facility's CMS form 671 dated 8/20/24 showed 75 residents resided in the facility. On 8/20/24 at 9:56 AM, V11 (Dietary Manager) accompanied the surveyor during the kitchen tour. A pan of raw, chicken thighs was marinating in a metal pan on the shelf. This pan was partially covered with loose saran wrap. The end of the saran wrap was curled back, exposing the raw chicken. The metal pan was labeled with a prepared dated of 8/13/24 and a use by date of 8/19/24. V11 said this meat is marinated ahead of time, then the dietary staff will seal it in vacuum, freezer bags and use it the pre-marinated meat at a later date. V11 said the meat should have been frozen prior to the 8/19/24 use by date, on the label. V11 stated, I'll have to throw this out. V11 said the food is labeled to ensure the food quality and to prevent foodborne illness.…

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 implement a treatment for a stage II pressure injury for two days. This applies to 1 of 3 residents (R49) reviewed for pressure injuries in the sample of 18. The findings include: R49's progress notes showed she was sent from the facility to a local area hospital on 7/20/24. R49's progress notes showed she was admitted to the hospital for a lung abscess and diarrhea. R49's progress notes showed she was admitted back to the facility on 8/10/24. R49's 8/10/24 admission Note from 6:00 PM showed, Sacrum (area above buttocks) open areas and redness. (The note does not document any treatment was applied or any notifications were made.) R49's 8/12/24 Sacral Wound Assessment showed the wound was a stage II pressure injury, it was open, it was draining, and it was present on admission. The assessment was authored by V5 Certified Wound Care Nurse. R49's August 2024 Treatment Administration Record (TAR) showed the first documented wound treatment for her sacrum was completed on 8/14/24. On 8/22/24 at 10:51 AM, V5 stated the wound 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 supervise a resident with swallow precautions while eating for 1 of 4 residents (R174) reviewed for safety in the sample of 18. The findings include: R174's face sheet printed on 8/21/24 showed admitting diagnoses including but not limited to Parkinson's disease, pneumonitis due to inhalation of food and vomit, chronic obstructive pulmonary disease, and dysphagia (difficulty swallowing). R174's admission assessment dated [DATE] showed no cognitive impairment, no natural teeth, and the use of dentures. R174's physician orders showed orders start dated 8/16/24 for a mechanical soft diet and may suction as needed. On 8/21/24 at 9:36 AM, R174 was in bed and alone in his room. A breakfast tray of cut up pancakes and sausage was in front of him. A bowl of applesauce and glass of juice were on the tray. R174 was feeding himself and coughing intermittently. A sign was posted on the wall that showed 1:1 feeder (one to one feeding assistance). 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 monitor residents while taking Physician Prescribed medications for 2 of 3 resident (R1, R32) reviewed for medication administration in the sample of 18. The findings include: 1. The facility face sheet for R1 shows she was admitted to the facility with diagnoses to include chronic obstructive pulmonary disease, type 2 Diabetes Mellitus, congestive heart failure and chronic lymphocytic leukemia. The facility assessment dated [DATE] shows R1 to be cognitively intact and is dependent on staff for her activities of daily living. On 8/21/24 at 2:34 PM, R1 said the night nurse V16 Licensed Practical Nurse brings her morning medications to her at 5 AM. R1 said she wears a CPAP and it takes her a minute to remove this and to wake up enough to take pills at that time of the day. R1 said V16 just leaves the medicine on my table, gives me my insulin and leaves the room. R1 said most times she drops the medications so they never get taken. R1 said…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure isolation precautions were maintained to prevent cross contamination for 2 of 7 residents (R61, R49) reviewed for infection control in the sample of 18. The findings include: 1. On 8/20/24 at 10:55 AM, R61 was lying in bed on a pressure reduction mattress and an intravenous catheter (IV) line was visible in her right upper arm. R61 was fully alert and oriented. R61 stated she has a sore on her buttocks and needed an IV antibiotic to treat an infection she had in her urine. R61's room door did not have any type of signage or precautions posted. Other resident rooms on the same hallway showed signs that indicated enhanced barrier precautions were required for residents with wounds or invasive medical devices. On 8/20/24 at 12:44 PM, a newly placed isolation sign and PPE (personal protective equipment) were noted on the door of R61's room. The sign showed contact isolation precautions and PPE needed prior to entering the room. R61'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 interview and record review the facility failed to ensure a resident's POA (Power of Attorney) was notified immediately after a resident sustained a fall with injury and sent out to the local hospital. This applies to 1 of 4 residents (R3) reviewed for notification in the sample of 4. The findings include: R3's face sheet shows she is an [AGE] year-old female with diagnosis including urinary tract infection, chronic kidney disease, COPD, unspecified dementia, restlessness and agitation, and muscle weakness. R3's Fall Risk Evaluation dated 1/6/24 shows she is a HIGH risk for falls. On 1/16/24 at 10:28 AM, V18 (R3's POA) said she came to the facility to visit her mom on 1/10/24. When she went to R3's room she was not there. I was asking the staff where my mother was and staff told me she was sent out to the hospital. I was not notified of my mom having another fall and being sent out to the local hospital. On 1/16/24 at 10:53 AM, V14 (RN) said she was R3's nurse on 1/10/24. Sometime during lunch time, she…

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 interventions, develop a care plan and obtain treatment orders for 2 of 3 residents (R1 and R3) reviewed for pressure wounds in the sample of 5. The findings include: 1. On Thursday, 12/14/23 at 11:57 AM, V4, Assistant Director of Nursing (ADON)/Registered Nurse (RN) and V6, Certified Nursing Assistant (CNA) positioned R1 so her buttocks could be visualized. R1 had two dressings to her buttocks, and both were dated 12/11/23 (Monday). R1's Order Summary Report dated 12/14/23 shows an active order(s) for her sacrum to be cleaned with normal saline solution, patted dry, apply Medihoney (wound paste) to wound bed and cover with calcium alginate and a dry dressing every day shift Monday, Wednesday, Friday, and as needed. R1's Treatment Administration Record for 12/1/23-12/31/23 shows R1's sacral treatment was not completed on 12/13/23, as it was not signed off by the nurse. R1's Wound Summary shows R1 developed a pressure wound 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.

Based on observation, interview and record review the facility failed to ensure a fluid restriction was being followed and residents with congestive heart failure had weekly weights completed. The facility failed to ensure a resident with MASD (moisture associated skin dermatitis) had an initial assessment completed and orders for wound care prior to the application of a dressing. This applies to 4 of 4 residents (R11, R4, R277, & R276) reviewed for quality of care in the sample of 22. The findings include: 1. On 10/3/23 at 12:32 PM, R11 had a large cup that had markings on the side of the cup that went up to 1000 ml. (milliliter)There was ice water in the cup, and it was at the 700 ml line on the cup. At 12:55 PM, R11 was in the dining room eating and drank a 233 ml can of a soft drink. The meal ticket on R11's food tray showed, NAS (no added salt) regular diet; fluid restriction. Check binder for pre-planned meal. Do not take order; fluid restriction -2 times per meal. Drinks and condiments on back of ticket. The back of R11's meal ticket just had cola written on it. The TAR…

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 code status was consistently documented in the medical record for 1 of 1 residents (R39) reviewed for advance directives in the sample of 22. The findings include: R39's electronic face sheet printed on 10/5/23 showed R39 has diagnoses including but not limited to femur fracture, urinary tract infection, end stage renal disease, congestive heart failure, type 2 diabetes, and gastroesophageal reflux disease. R39's physician's orders for life sustaining treatment (POLST) showed, Do Not Resuscitate. R39's care plan dated 7/27/23 showed, Resident/guest is a full code. R39's physician's orders showed, 8/9/23 full code 8/10/23 DNR (do not resuscitate). On 10/5/23 at 11:41AM, V14 (Registered Nurse) stated, In the event of an emergency, a resident's code status is immediately checked on the resident's banner in the computer system. It is a problem if the banner and orders do not match because they could be incorrectly treated. On 10/5/23 at 12:11PM, V2 (Director of Nursing) stated, In an emergency, the nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement preventative measures for a resident at risk for pressure ulcers, resulting in the resident obtaining a Stage 2 pressure ulcer. This applies to 1 of 2 residents (R277) reviewed for pressure in the sample of 22. The findings include: R277's electronic face sheet printed on 10/5/23 showed R277 has diagnoses including but not limited to metabolic encephalopathy, urinary tract infection, sepsis, chronic kidney disease stage 3, and congestive heart failure. R277's facility assessment dated [DATE] showed R277 was not admitted with any pressure ulcers and is at risk of developing pressure ulcers. R277's care plan dated 9/3/23 showed, (R277) has actual impairment to skin integrity related to vascular insufficiency. 9/22/23- left heel-open blister R277's skin risk assessment dated [DATE] showed R277 is a moderate risk for skin breakdown. Protect elbows and heels if being exposed to friction, protect heels, use pressure redistribution…

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

Based on observation, interview and record review the facility failed to ensure a drainage bag was kept below the level of the bladder. The facility failed to ensure the catheter tubing was not kinked, positioned under the resident's leg, and have a secure device in place for the indwelling urinary catheter tubing for 1 of 1 residents (R4) reviewed for catheters in the sample of 22. The findings include: On 10/3/23 at 1:15 PM, R4 was laying on her back in bed complaining of pain to her buttocks. R4's indwelling urinary catheter tubing was occluded under her right leg. V8 CNA (Certified Nursing Assistant) was on the other side of the curtain feeding R4's roommate. When V8 was finished she came over and to R4 and saw the tubing was under the R4's left leg. V8 stated that the tubing should be over R4's leg so the urine will flow. V8 lifted the bag above the level of the bladder and placed it on R4's bed. R4 stated her catheter hurt on the outside area. R4 did not have an anchor device in place to her catheter tubing. V8 unfastened R4's brief and pulled on her catheter tubing. V8…

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 a residents percutaneously inserted central catheter (PICC) dressing, failed to measure a resident's PICC line. These failures apply to 1 of 1 residents (R277) reviewed for PICC line care in the sample of 22. The findings include: R277's electronic face sheet printed on 10/5/23 showed R277 has diagnoses including but not limited to metabolic encephalopathy, urinary tract infection, sepsis, chronic kidney disease stage 3, and congestive heart failure. R277's facility assessment dated [DATE] showed R277 has mild cognitive impairment and receives intravenous medications. On 10/4/23 at 9:17AM, R277's PICC line dressing showed a date of 9/4/23 and was peeling on all of the edges. R277 stated she is unsure of when the dressing was last completed and nobody really touches it. I'm not exactly sure what it's for. R277's physician's orders dated 9/3/23 showed, Midline: Measure external catheter length every 7 days with dressing change every…

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

Based on observation, interview and record review the facility failed to have orders for the use of a CPAP (continuous positive airway pressure) machine, a care plan in place for the use of CPAP or keep the nasal mask off the floor for 1 of 1 residents (R133) with CPAP in the sample of 22. The findings include: On 10/03/23 at 10:41 AM, R133 was laying in bed on his back and stated he came into the facility on Saturday (9/30/23) after having a mini stroke. R133 had a CPAP machine next to his bed with the nasal mask laying on the floor as well as the head strap. On 10/4/23 at 12:40 PM, R133 was sitting up in a wheelchair in his room for lunch. R133's CPAP machine was next to his bed with 4 jugs of distilled water sitting on the floor near the CPAP machine. R133 stated he has had the CPAP machine for a couple of years. R133 stated he was told he needed it and thinks he was told he had sleep apnea. R133 stated staff fill his machine with distilled water at night because he is unable to do that because he can't reach the jugs of water. The Face Sheet dated 10/4/23 for R133 showed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a medication was not left at bedside for 1 of 1 resident (R65) reviewed for medications. The findings include: R65's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure with hypoxia, cardiomegaly, heart failure, muscle weakness, and need for assistance with personal care. R65's facility assessment dated [DATE] showed he has moderate cognitive impairment and requires limited assistance from staff for most cares. R65's October 2023 physician order sheet showed, 9/7/23 Albuterol Sulfate Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for SOB (shortness of breath). On 10/4/23 at 8:38 AM, R65 was in his bed. There was an inhaler on the bedside table with an aerochamber (assist device) next to it. On 10/4/23 at 8:38 AM, R65 said he has used the inhaler but is not sure what it is for or how he is supposed to use it. On 10/4/23 at 8:44 AM, V5 RN…

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 as needed psychotropic medication order had an end date. This applies to 1 of 5 residents (R37) reviewed for psychotropic medications in the sample of 22. The findings include: R37's admission Record (Face Sheet) showed an original admission date of 9/18/23. R37's Order Summary Sheet showed an order for Alprazolam 0.5 milligrams to be given every 12 hours as needed for anxiety. On 10/05/23 at 11:06 AM, V10 Assistant Director of Nursing stated she is the unit manager for R37's unit. V10 said the unit managers are responsible for monitoring the psychotropic medication orders of the residents. V10 said all initial orders for psychotropic medications need to have a 14 day stop date. V10 said, while reviewing R37's alprazolam order in the electronic health record, the column title end date for R37's alprazolam order is blank. V10 said the end date column is where a stop date for the alprazolam would be listed. V10 stated she was not aware psychotropic medications needed a prescribed end date if the medication…

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

Based on observation, interview, and record review the facility failed to ensure a resident received a palatable sandwich. This applies to 1 of 1 resident (R227) reviewed for food in the sample of 22. The findings include: R227's admission Record (Face Sheet) showed an admission date of 9/21/23 with diagnosis of macular degeneration (a condition which can cause blurring of vision). On 10/03/23 at 1:08 PM, V9 R227's daughter exited R227's room with a sandwich. The bread of the sandwich had several green moldy spots on the bread. R227 stated the sandwich was moldy and she could get sick from this. On 10/3/23 at 1:15 PM, V11 Dietary Manager entered R227's room and stated the sandwich was in the unit refrigerator, had R227's name on it, and the sandwich should have been thrown out. On 10/05/23 at 10:00 AM, V9 stated the sandwich was delivered by staff and did not come from R227's in-room refrigerator. V9 said, I was the one that found the mold on the sandwich. The sandwich did not come from the refrigerator in her room. She can't see, she has macular degeneration, if I wasn't here, she…

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

Based on observation, interview, and record review, the facility failed to wear personal protective equipment (PPE) in a manner to prevent the spread of COVID-19 in a resident room (R45), failed to wear personal protective equipment in (R45, R70) resident rooms under contact/droplet precautions, and failed to provide catheter care in a manner to prevent cross contamination for a resident (R4). These failures apply to 3 of 8 residents reviewed for infection control in the sample of 22. The findings include: 1) R45's electronic face sheet showed R45 has diagnoses including but not limited to Alzheimer's disease, anxiety disorder, and hypertension. The facility's COVID-19 positive resident list provided on 10/4/23 showed R45 tested positive for COVID-19 on 10/2/23. R45's physician's orders dated 10/2/23 showed, COVID isolation for COVID positive for 10 days. R45's undated care plan showed, (R45) requires droplet isolation related to COVID. Verify that proper isolation notifications are in place and appropriate protective equipment inside and outside room and follow facility policy 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.