Mt Zion Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to safely transport a resident resulting in two falls from the wheelchair. The facility also failed to document fall investigations for two falls. These failures affected one of three residents (R9) reviewed for falls on the sample list of 31. Findings Include:The facility's Accidents and Incidents Policy dated 7/1/23 documents that all accidents or incidents involving a resident will be documented in risk management, and the nursing team will complete an investigation that includes identification of the root cause and implementation of new interventions.R9's undated Medical Diagnoses List documents that R9 was diagnosed with Alzheimer's disease, adult failure to thrive, rhabdomyolysis, and unspecified abnormalities of gait and mobility.R9's Fall Risk assessment dated [DATE] documents that R9 was at high risk for falls due to being consistently disoriented, having one to two falls in the last three months, being chair-bound and/or requiring assistance,…

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 transcribe a physician ordered medication (Coumadin) to prevent blood clot formation, for a resident post-surgical procedure, and an underlying high-risk diagnoses for blood clot formation. This failure resulted in a significant medication error. This failure affected one of 20 residents (R4) reviewed for medications on the sample list of 31. Findings include:R4's Current Diagnoses List documents the following diagnoses, which significantly increase the likelihood of blood clot development: Unspecified Encounter of Shaft of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Pain Due to Internal Orthopedic Prosthetic Devices, Implants, and Grafts, Subsequent Encounter; Atrial Fibrillation; Cardiomyopathy, Unspecified; Nonrheumatic Mitral Valve Disorder; Occlusion and Stenosis of Carotid Artery, Unspecified; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina.R4's hospital discharge records document that R4…

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 residents dignity by failing to provide toileting in a timely manner. This failure affected one of five residents (R1) reviewed for dignity/incontinence care on the sample list of 3. Findings include:R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating R1 has no cognitive impairment.The same MDS documents that R1 is always continent of bowel and bladder, and that R1 requires substantial/maximal assistance to transfer on and off the toilet.On 12/09/25 at 1:05 p.m., R1 stated, As far as staff, they have never provided rough care. On the other hand, there was an incident last week that really upset me. A CNA (later identified as V37, Certified Nursing Assistant), I don't know her name, brought my breakfast in and rudely dropped my tray on the bedside table. She was upset because I asked her if she would take me to the bathroom before I ate. 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 interview and record review the facility failed to report misappropriation of an amethyst stone ring to Illinois Department of Public Health (IDPH), in a timely manner. This failure affected one of four residents (R12) reviewed for abuse/misappropriation on the sample list of 31.Findings include:R1's Minimum Data Set (MDS), dated [DATE], documents R1's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating R1 has no cognitive impairment.On 12/09/25 at 1:05 p.m., R1 became tearful while discussing the details of the theft of her credit card, which was investigated by the local police department. R1 then stated that her roommate, R13, could provide details about R12, who had a missing ring that occurred around the same time R1's credit card was stolen.On 12/09/25 at 1:30 p.m., R13 propelled her wheelchair into her shared room with R1. R13 stated, R12's family bought her a ring for her birthday just before Thanksgiving. She told the facility, and they looked for it but never…

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 investigate two resident (R1 and R12) allegations of misappropriation. R1 and R12 are two of four residents reviewed for abuse/misappropriation on the sample list of 31.Findings include:1.) R1's Minimum Data Set (MDS), dated [DATE], documents R1's Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating R1 has no cognitive impairment.On 12/09/25 at 1:05 p.m., R1 became tearful while discussing the details of the theft of her credit card. R1 stated the missing credit card was investigated by the local police department, who arrested V6, Certified Nursing Assistant (CNA), after their investigation found that V6 had charged over $1,000 to the card. R1 stated that V3, Regional Nurse Consultant, spoke with her but never spoke with her roommate, R13. R1 stated that R13 knew all about R1's stolen credit card and also knew about R12's missing ring around the same time.R13's MDS, dated [DATE], documents R13's BIMS score as 15 out of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement physician's orders for one of three residents (R9) reviewed for following plans of care on the sample list of 31.Findings Include:R9's Hospice admission Orders dated [DATE] document that R9 was admitted to hospice care. To protect R9's skin, staff were instructed to use incontinence pads instead of incontinence briefs.On [DATE] at 1:21 PM, V29, Licensed Practical Nurse (LPN), stated she was not aware that staff were supposed to use incontinence pads instead of incontinence briefs for R9.On [DATE] at 12:52 PM, V45, Certified Nursing Assistant (CNA), stated she was not aware that staff were supposed to use incontinence pads instead of incontinence briefs for R9.On [DATE] at 12:57 PM, V37, Certified Nursing Assistant (CNA), stated she was never told that R9 was to use incontinence pads instead of incontinence briefs and that she and other staff continued to use incontinence briefs until R9's death on [DATE].On [DATE] at 2:35 PM, V2, Director 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 maintain an accurate medical record for one resident (R1) of three residents reviewed for medical records in a sample list of three residents.Findings include:R1's Care Plan updated 10/10/25 includes the following diagnoses: Osteoporosis, Anxiety Disorder, Left Hemiparesis, Major Depression, Delusional Disorder, History of Right Shoulder Replacement, Parkinson's Disease, Type II Diabetes, and History of Cerebral Infarction. R1's Fall Risk assessment dated [DATE] documents R1 is at high risk for falls. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact.R1's CAT (Computerized Axial Tomography) scan dated 8/16/25 at 12:07PM documents Bilateral Nasal Bone Fracture. Soft Tissue Hematoma noted overlying the inferior aspect of the frontal bone.On 10/14/24 at 1:30PM R1 was seated in her room in her wheelchair. Both foot pedals were in place. When asked if R1 recalled falling out of her wheelchair about a month ago R1 stated I sure do. I…

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 protect a resident's right to be free from physical abuse for one of four residents (R3) reviewed for abuse in the sample list of eight. Findings Include: The facility's Abuse Policy dated 1/9/24 documents it is the responsibility of the facility staff to assure that all residents remain free from abuse. The facility affirms the right of its residents to be free from abuse. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury. Physical abuse is the infliction on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, and kicking. The facility's Final Report and Conclusion of Incident form dated 3/7/25 documents on 3/2/25 at 12:30 PM R3 reported she was sitting in the dining room in her normal spot at the table when R2 came over in her wheelchair and told her to get out of her spot. R3 did not move and R2 swung 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 assess a resident before transferring to a wheelchair following a fall. This failure affects one (R3) of four residents reviewed for falls in the sample list of four. This past non-compliance occurred from 5/27/24 to 5/28/24. Findings include: The facility's Accidents & Incidents policy with initiated date of July 01, 2023 documents in section 2. Assisting Accident/Incident Victims: A. Render immediate assistance. DO NOT move the victim until he/she has been examined for possible injuries. B. If assistance is needed, summon help. If you cannot leave the victim, ask someone to report to the nurses station that help is needed, or if possible, use the call system located in the resident's room to summon help. R3's Minimum Data Set completed on 05/10/2024 documents a Brief Interview for Mental Status score of 14 indicating R3 is Cognitively Intact. R3's Care Plan dated 4/30/24 states R3 is at risk for falls and injuries related to Metabolic Encephalopathy, Hypertension, Coronary Artery Disease and Multiple Sclerosis. R3'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 record review and interview the facility failed to provide a dependent resident, who is a two-person assist, a safe transfer in order to prevent a fall. This failure affected one of seven residents (R1) reviewed for falls/safe transfer on the sample list of seven. Findings include: R1's Minimum Data Set, dated [DATE] documents the following: R1's usual activity performance is 5. C (coded 2), Toileting Hygiene- current level of care, Substantial to Maximal Assistance-Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort and 5. D (coded 2) Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, Substantial to Maximal Assistance-Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half effort. R1's Hospice Care Plan dated 3/16/24 documents the following: R1's Hospice Plan of Care documents: Brief Narrative Statement '(Review the individual's…

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

Based on observation, interview, and record review, the facility failed to ensure the proper storage of medications and biologicals by allowing non-licensed personnel access to nurses medication rooms and not ensuring nurses medication cart was supervised by a licensed nurse. This failure has the potential to affect all 62 residents residing in facility. Findings include: The facility policy titled 'Mediation Storage Policy', dated 7/1/2023, documents the facility drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications may have access to locked medications. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes ) containing drugs and biologicals shall be locked when not in use. Unlocked medications carts are not left unattended. The facility Room Roster, dated 2/6/24, documents 62 residents reside in facility. 1. On 2/7/24 at 8:15 AM, V18, Maintenance Director, exited the locked nurses 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 provide the services of a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 62 residents residing in the facility. Findings include: On 2/6/24 at 9:55 AM, V3, Dietary Manager, was actively managing kitchen personnel and directing the food sanitation and preparation activities in the facility's kitchen. On 2/6/24 at 9:55 AM, V3 stated, I am the Dietary Manager. I have a CFM (Certified Food Manager, sanitation) certificate. This certificate was done online and I answered 120 questions. It took one day. V3's certificate for Certified Food Manager was dated issued 11/1/21, and documented valid for 3 years from that date. On 2/6/24 at 10:00 AM, V3 further stated, I do not have a CDM (Certified Dietary Manager) nor CFPP (Certified Food Protection Manager) certificate. I do have a Food Sanitation (Cook) certificate since 1994. V3 then stated, I do not have any military experience. I started at this facility as Dietary Manager 7/23/21. On 2/7/24 at 2:51 PM, V3…

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 Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to maintain infection prevention procedures to provide a sanitary environment during dietary meal services. This failure has the potential to affect all 62 residents residing in the facility. B. Based on observation, interview, and record review the facility failed to follow a physician order for Contact Isolation Precautions for one (R12) resident of one resident reviewed for infection control in a sample list of 28 residents. Findings Include: A. On 2/6/24 at 9:50 AM, V1, Administrator, stated the facility is in outbreak status for Covid-19. On 2/6/24 at 3:15 PM, V2, Director of Nursing/ Infection Preventionist, confirmed the facility was in outbreak status with residents, and staff, testing positive for Covid-19. The facility's Line List for Covid-19 Outbreaks in Long Term Care facilities, dated 1/29/24 through 2/8/24, documents 19 residents tested positive for…

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

Based on interview and record review, the facility failed to obtain Physician responses to Registered Pharmacist recommendations, failed to implement physician responses, and failed to maintain records of medication regimen review reports. This failure affects three residents (R14, R31, and R48) out of five reviewed for unnecessary medications on the sample list of 28. Findings include: 1. R31's Pharmacy Medication Regimen Review (MRR), dated 9/14/23, documents a Registered Pharmacist (V20) recommendation, This resident started the anti-psychotic Prochlorperazine 10 milligrams (mg) every 6 hours as needed (PRN) on 7/23/23. This medication has never been used. According to regulatory guidelines, anti-psychotic medications on a PRN basis must be limited to 14 days. R31's Physician (V9) responded to the recommendation to discontinue the medication Prochlorperazine, signed and dated this order 10/6/23. R31's historical Physician Order Sheet, dated (printed) 2/8/24, documents the medication Prochlorperazine was not discontinued by the facility until 11/28/23. R31's 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 interview and record review, the facility failed to complete initial and quarterly psychotropic medication assessments, psychotropic Abnormal Involuntary Movement Scale (AIMS), and psychotropic gradual dose reductions for six of seven residents (R8, R27, R29, R31, R48, R168) reviewed for psychotropic medications on the sample list of 28. Findings Include: 1. R29's Medical Diagnoses List, dated February 2024, documents R29 is diagnosed with Dementia, Anxiety, and Major Depression. R29's Physician Order Sheet, dated February 2024, documents orders for Trazodone (Sedative) 50 milligrams at bedtime for Major Depression, Sertraline (Anti-depressant) 25 milligrams daily for Major Depression, and Lorazepam (Anti-anxiety) 0.5 milligrams daily for Anxiety. R29's Medical Record had no record of any Psychotropic Medication Assessments completed for these medications since March 2023. 2. R168's Medical Diagnoses List, dated February 2024, documents R168 is diagnosed with Dementia with Behavioral Disturbance,…

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 incontinence care for one (R5) resident out of one resident reviewed for resident rights in a sample list of 28 residents. Findings include: R5's Minimum Data Set (MDS), dated [DATE], documents R5 as moderately cognitively impaired. This same MDS documents R5 as requiring maximum assistance for bathing, dressing, personal hygiene, bed mobility and toileting. This same MDS documents R5 requires the use of a total mechanical lift for transfers. On 2/6/24 at 11:30 AM, V11, Certified Nurse Aide (CNA), performed incontinence care for R5 with R5's room door open. R5's privacy curtain was not pulled. R10 (R5's roommate) had full visual site of R5's perineal area. R5's perineal area was not covered. On 2/6/24 at 11:52 AM, V11, Certified Nurse Aide (CNA), stated R5's privacy curtain should have been pulled. V11, CNA, stated V11 was aware R10 was in the room and could see 'everything'. V11, CNA, stated R5 does not like 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 interview and record review, the facility failed to complete a discharge summary/recapitulation of stay for one (R64) resident out of one resident reviewed for discharge in a sample list of 28 residents. Findings include: R64's undated Face Sheet documents R64 admitted to the facility on [DATE], and discharged to an Assisted Living Facility on 11/13/23. This same Face Sheet documents medical diagnoses of Pneumonia due to other Bacteria, Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, and Hypertension. R64's Physician Order Sheet (POS), dated November 2023, documents a physician order, dated 11/13/23, of OK to discharge to assisted living with current orders. R64's Minimum Data Set (MDS), dated [DATE], documents R64 was moderately cognitively impaired. R64's Nurse Progress note, dated 11/13/23 at 2:59 PM, documents, (R64) discharged to Assisted Living Facility to start hospice services. Transportation was provided by family. Vitals are stable. No complaints of pain. Report…

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 implement post-fall nursing interventions according to a resident's care plan for fall prevention. This failure affects one resident (R26) out of five reviewed for accidents on the sample list of 28. Findings include: R26's Care Plan for fall prevention, dated initiated 4/11/16, documents, I am at risk for falls r/t (related to) unaware of safety needs, Confusion, Psychoactive drug use, Gait/balance problems. I will often transfer myself even though I know I am not supposed to. The nursing intervention documented, initiated 12/28/23, documents floor mat added next to the bed for safety. R26's Fall Risk Assessments, dated 1/27/24, 1/18/24, 12/8/23, and 10/2/23, all document R26 as a high risk for falls with scores of 19, 19, 17, and 15, respectively, with 10 and higher being rated as high risk. R26's Nursing Progress Notes, dated 1/27/2024, document, CNA (Certified Nursing Assistant) alerted this writer that resident was on the floor. When arrived to resident's room, found resident lying on the floor between…

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 the urinary catheter every 28 days for one resident (R315) out of two residents reviewed for urinary catheters in a sample list of 28 residents. Findings Include: 1. R315's undated Face Sheet documents an admission date of 1/9/24. This same Face Sheet documents R315's medical diagnoses of Urinary Tract Infection, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Type 2 Diabetes Mellitus Without Complications, Bladder-Neck Obstruction, Obstructive And Reflux Uropathy, Hydronephrosis With Renal And Ureteral Calculous Obstruction. R315's Minimum Data Set (MDS), dated [DATE], documents R315 as cognitively moderately impaired. This same MDS documents R315 as requiring maximum one person assist for toileting, bathing, and catheter/perineal care. R315's Physician Order Sheet (POS), dated January 2024, documents a physician order starting 1/09/24 to change the urinary catheter every 28 days. On 2/7/24 at 11:00 AM, R315's…

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

Based on interview and record review, the facility failed to provide the services of a Registered Nurse for eight consecutive hours a day. This failure has the potential to affect all 43 residents residing in the facility. Findings include: The facility's November 2022 schedule, dated 11/24/22, does not document a Registered Nurse working eight consecutive hours for the day. On 12/6/22 at 9:30 AM, V2, Director of Nursing, stated the facility did not have a Registered Nurse in the facility on 11/24/22, and the facility provides skilled nursing care. The facility's Census and Condition report, dated 12/4/22 signed by V3, Care Plan Coordinator, documents there are 43 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to ensure an expired over the counter cough syrup was discarded and not available for use. This failure had the potential to affect all 43 residents residing in the facility. Findings include: On 12/05/22 at 3:00 PM, the medication cart on the 100 hallway was reviewed. This cart had a bottle of Dextromethorphan (cough syrup) that had an expiration date of August of 2022. At that time, V13, Licensed Practical Nurse, looked at the expiration date and confirmed the medication was expired. On 12/6/22 at 10:10 AM, V2, Director of Nursing, stated the cough syrup is a stock medication, and stock medications can be used for any resident in the facility. The facility's Census and Condition report, dated 12/4/22 signed by V3, Care Plan Coordinator, documents there are 43 residents residing in the facility. The Undated Storage of Medication policy documents, V. All discontinued/expired medications are to be removed from the active storage medication use area.

Based on observation, interview, and record review, the facility failed to ensure that chemical sanitizing agent was being dispensed accurately in the low temperature dish washer to ensure that dishes were properly sanitized. This failure has the potential to affect all 43 residents in the facility. Findings include: The facility's Census and Condition report, dated 12/4/22 signed by V3, Care Plan Coordinator, documents there are 43 residents residing in the facility. On 12/5/22 at 3:30PM, V2, Director of Nursing, stated there are no residents in the facility who do not eat by mouth, and all eat food served from the kitchen. The facility provided document, Dishwasher Temperature Log for Low Temp/Chemical Sanitizing Machines, dated December 2022, document was not filled out on 12/5/22 at 10:50AM. On 12/5/22 at 11:00AM, V11, Dietary Aide, tested the automatic dishwasher for sanitizer level after three completed cycles. The chemical test tape did not react when testing was completed. The test strip did not show any chemical residual in the sanitizing rinse water. V11, Dietary Aide,…

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, a facility employee failed to self report an illness and continued to work in the kitchen, handling ready to eat food products, putting residents at risk for food borne illness. This failure has the potential to affect all 43 residents in the facility. Findings include: The facility's Census and Condition report, dated 12/4/22 signed by V3, Care Plan Coordinator, documents there are 43 residents residing in the facility. On 12/5/22 at 3:30PM, V2, Director of Nursing, stated there are no residents in the facility who do not eat by mouth, and all eat food served from the kitchen. The facility provided November dietary schedule documents V11, Dietary Aide, was scheduled to work 6:00AM to 2:00PM on 11/25/22. V11's facility provided time card documents V11 worked from 5:48AM until 7:30AM. On 12/6/22 at 1:15PM, V15, Cook, stated, I was working the day (11/25/22) when (V11, Dietary Aide) was sick. She (V11) complained that she had been vomiting and had diarrhea and that she had a fever. On 12/6/22 at 1:55PM, V17, Dietary Aide, stated, I…

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 designate an individual as Infection Preventionist in the facility who has completed specialized training in infection prevention and control. This failure has the potential to affect all 43 residents in the facility. Findings include: The facility's Census and Condition report, dated 12/4/22, signed by V3, Care Plan Coordinator, documents there are 43 residents residing in the facility. On 12/4/22 at 9:10AM, V1, Administrator, stated V4, the facility Infection Preventionist, has not completed infection control training. On 12/6/22 at 9:54 AM, V4, Infection Preventionist, said she was responsible for keeping the log on employee illness for the facility. However, V4, Infection Preventionist, had not followed up on employee illness, timelines, symptoms or the relationship between employee and resident illness. V4 reviewed the November and December 2022 employee infection control screening log and stated, I keep logs of the employee illness that I know about, but I can see that it is incomplete. On 12/6/22 at 12:30 PM, V5,…

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 notify the physician of elevated blood glucose levels on 31 separate occurrences for one of two residents (R37) reviewed for insulin use on the total sample list of 29. Findings include: R37's medical record documents under physician orders, Start date: 7/28/22, Call V19 (Physician) with finger sticks (blood glucose levels) above 300. R37's medical record documents under physician orders, Start date: 9/6/22, Insulin Aspart Solution Pen, inject as per sliding scale, Notify Doctor if (blood glucose level) is less than 60 or greater than 350. R37's Medication Administration Records dated October 2022 documents the following Blood Glucose Level results: At 11:30 AM on 10/2/22- 358, 10/9/22 - 385, 10/17/22- 361, 10/19/22 - 394, 10/20/22 - 363, 10/21/22 - 352, 10/24/22 - 370, 10/25/22 - 366, 10/26/22 - 378, 10/27/22 - 375, 10/30/22 - 375, and 10/31/22 - 414. At 4:30 PM on 10/7/22 - 384, 10/9/22 -403, 10/12/22 - 371, 10/21/22 - 380 and 10/31/22 - 368. At 8:00 PM on 10/1/22 - 354, 10/16/22 - 450 and 10/22/22 -390. R37's 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 2.) R97's Medication Administration Record (MAR), dated December 2022, documents R97 receives Amitriptyline Hydrochloride (antidepressant) 25 Milligrams (mg) one tablet by mouth in the evening, Citalopram Hydrobromide (antidepressant) Tablet 20 mg one tablet by mouth in the morning, Seroquel (anti-psychotic) 25 mg two tablets by mouth at bedtime. This MAR documents that these medications are being used for Depression. R97's electronic medical record documents R97 was admitted to the facility on [DATE]. R97's medical record does not contain documentation for the medical rationale of the use of duplicative medications for Depression, or an initial evaluation of R97's use of psychotropic medications. On 12/5/22 at 11:17 AM, V2, Director of Nursing, stated R97's psychotropic medications are for Depression. V2 stated they had not completed an assessment or initial evaluation for the use of R97's psychotropic medications. V2 stated she is not sure why they are using duplicative therapy or an antipsychotic for R97'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 one resident (R16) was not subjected to verbal/mental abuse by a staff member. R16 is one of two residents reviewed for abuse from a sample list of 29 residents. Findings include: R16's Care Plan, initiated 9/19/22, includes the following diagnoses: Unsteadiness on Feet, Dementia, Psychotic Disturbance, Anxiety, and Dysphasia. This Care Plan does include interventions related to R16's vulnerability to abuse related to R16's physical weakness and hearing impairment. R16's Minimum Data Set (MDS), dated [DATE], documents R16 is Severely cognitively impaired and requires hearing aides to understand when spoken to and could not be interviewed. The facility's investigation of incident involving (R16), dated 11/6/22, documents There are two eye witnesses from the dietary department who report V20, Certified Nurse's Assistant (CNA) told (R16) to 'sit the F* (expletive) down when (R16) stood up from wheelchair. One eye witness reported that (V20) also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a physical restraint assessment demonstrating medical necessity, and failed to attempt less restrictive interventions before applying a physical restraint to one resident (R34) of one resident reviewed for restraints in a sample list of 29 residents. Finding Include: R34's Care Plan, updated 11/2/22, includes the following diagnoses: Generalized Anxiety Disorder, Dementia, Muscle weakness, Psychotic Disturbance, and Gait Abnormalities. R34's Minimum Data Set (MDS), dated [DATE], documents (R34) is severely cognitively impaired and able to walk with assistance of one staff. R34's Care Plan, revised 1/2/22, documents as an intervention under falls, May have (lap top cushion) in place while in wheelchair for safety. R34's most recent restraint evaluation is dated 7/4/22. There is no documentation to indicate that less restrictive interventions were attempted prior to placing the lap top cushion. On 12/04/22 at 10:42 AM, R34 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 record review and interview, the facility failed to address a significant weight loss for one resident (R16) and a physical restraint for another resident (R34). This failure effects two of twelve residents reviewed for Care Plans in a sample list of 29. 1.) R16's Care Plan, initiated 9/19/22, includes the following diagnoses: Unsteadiness on Feet, Dementia, Psychotic Disturbance, Anxiety, and Dysphasia. R16's weight tracking, dated 09/19/2022, documents R16 weighed 114 lbs. R16's weight tracking, dated 11/02/2022, documents R16 weighed 107 pounds. This is a 6.14 % weight loss. R16's Care Plan does not address significan weight loss. 2.) R34's Care Plan, updated 11/2/22, includes the following diagnoses: Generalized Anxiety Disorder, Dementia, Muscle weakness, Psychotic Disturbance, and Gait Abnormalities. On 12/04/22 at 10:42 AM, R34 was seated in a wheelchair with lap top cushion in place. R34 does not respond to verbal stimuli, and is unable to remove lap top cushion. V3, Licensed Practical Nurse (LPN), confirmed R34 is unable to remove the lap top cushion without…

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 cleanse a wound during treatment for one resident (R40) of one resident reviewed for Pressure ulcers in a sample list of 29 residents. Findings include: R40's Care Plan, reviewed 11/2/22, includes the following diagnoses: Morbid Obesity, Muscle Weakness, and Pressure Ulcer of Left Heel stage III. R40's Treatment Administration Record (TAR) for 12/1/22 through 12/31/22 includes a treatment order for: Cleanse Left heel pressure injury with Normal Saline, apply skin prep to surrounding skin, apply collagen sheet with silver, Calcium Alginate over collagen, cover with foam dressing and secure with retention tape daily. every day shift for wound healing. On 12/6/22 at 11:01 AM, V14, Licensed Practical Nurse (LPN), completed wound care for R40. At this time, there was no dressing in place to R40's heel wound. R40 stated, It probably came off when they dressed me and changed my socks. V14 applied skin prep, but did not cleanse wound prior to skin prep. V14 dabbed the center of the wound with a saline gauze, but…

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 the root cause of an incident resulting in a skin tear for one of three residents (R6) reviewed for accidents on the total sample list of 29. Findings include: R6's medical record documents on 10/10/2022 at 9:41 PM, Certified Nursing Assistant gave resident shower and noticed a skin tear following transfer to bed from chair, skin tear to lower left leg appears to have resulted from leg contact with shower chair, resident has signs and symptoms of pain only to touch at site. R6's Ulcer/Wound form documents, skin tear 4 centimeters in length to left lower extremity identified on 10/10/22. R6's medical record did not include revisions to R6's care plans to prevent future occurences after the skin tear occurred on 10/10/22. On 12/05/22 at 1:30 PM, V2, Director of Nursing, stated, I am not able to locate an investigation for the skin tear on 10/10/22; there was no investigation completed.

Based on observation, interview, and record review, the facility failed to develop written resident care policy and procedures for aerosol drug delivery system storage in residents rooms, and failed to ensure personal aerosol drug delivery system equipment was stored properly to prevent cross-contamination for two of two residents (R8 and R15) reviewed for respiratory therapy on the total sample list of 29. Findings include: 1.) On 12/4/22 at 8:47 AM and on 12/5/22 at 10:35 AM, R8 had an aerosol generating delivery system (mask and tubing) lying directly on top of R8's nightstand beside with other personal articles in close proximity. On 12/06/22 at 10:00 AM, V2, Director of Nursing, stated nebulizer masks and tubing (aerosol drug delivery system equipment) should be stored inside of clear bags in resident rooms while not in use. On 12/06/22 at 10:45 AM, V1, Administrator, stated we have no written policy for nebulizer mask storage. 2.) On 12/04/22 at 8:30 AM, R15's nebulizer mouth piece was lying directly on top of a table beside R15's bed and was not bagged. On 12/5/22 at 10:20…

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 offer one resident (R40) the opportunity to receive pneumococcal pneumonia vaccination. R40 is one of five residents reviewed for immunizations in a sample list of 29 residents. Findings include: R40's Care Plan, revised 12/2/22, documents R40 was admitted to the facility 4/19/22, and is over the age of 65. R40's Immunization Flow Sheet, printed 12/6/22, does not document R40 was offered either the PPSV 23 (Pneumococcal polysaccharide vaccine) or the PCV 13 (Pneumococcal conjugate vaccine) or the Prevnar 20 (Pneumococcal 20-valent congugate vaccine PPSV 23, as required. There is no documentation to support (R40) was educated regarding any of these vaccines and no documentation to support R40 refused the vaccine. On 12/6/22 at 11:00AM, V2, Director of Nursing, stated We do not have any documentation (R40) was offered or refused any of the pneumonia vaccines. The facility's policy Pneumococcal Pneumonia Vaccination Policy, dated April 2022, states, All residents admitted will be screened to determine eligibility for 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.