Alden Estates Of Naperville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess and provide appropriate splints and therapy services to maintain and/or prevent further progression of deformities or reduction in range of motion. This applies to 3 of 5 residents (R2, R23, R102) reviewed for Range of Motion (ROM) in the sample of 30. The findings include: 1. R2 has multiple diagnoses including rheumatoid arthritis, unspecified, generalized Osteo Arthritis, and Neuralgia according to the face sheet. R2's MDS (Minimum Data Set) dated March 12, 2024, identifies R2 as cognitively intact. R2 has functional limitations of ROM (Range of Motion) to one side of both upper and lower extremities. The same MDS shows R2 requires maximum to total assistance for most ADLs (Activities of daily living). On June 10, 2024 at 12:32 PM, R2 had contractures to the right hand and no splinting device was noted. R2 stated he uses his left hand to assist his right hand to perform basic tasks. R2 stated he is willing to be evaluated for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that gastric tube (g-tube) placement was checked prior to flushing the tube and administering medication. The facility also failed to administer g-tube flushes and medications using the proper technique. This applied to 1 of 1 resident (R147) reviewed for g-tube medication administration. The finding included: R147's EMR (Electronic Medical Record) showed R147 was admitted to the facility on [DATE], with diagnoses that included pneumonitis due to inhalation of food/vomit, dysphagia, major depressive disorder, anxiety, protein-calorie malnutrition, Right lung malignant neoplasm, Clostridium Difficile (C-diff) and adult failure to thrive. R147's MDS (Minimum Data Set) dated, May 27, 2024, showed R147 was cognitively intact and had history of coughing or choking during meals when swallowing. R147's care plan showed R147 required tube feeding and stoma site care due to dysphagia (difficulty swallowing). Interventions included . check…

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 follow the proper infection control practice when caring for a resident in contact isolation. This applies to 1 of 1 resident (R147) in sample of 30. The finding included: R147's EMR (Electronic Medical Record) showed R147 was admitted to the facility on [DATE], with diagnoses that included pneumonitis due to inhalation of food/vomit, dysphagia, major depressive disorder, anxiety, protein-calorie malnutrition, Right lung malignant neoplasm, Clostridium Difficile (C-diff) and adult failure to thrive. R147's MDS (Minimum Data Set) dated, May 27, 2024, showed R147 was cognitively intact. R147's care plan showed R147 was in a single room, in contact isolation related to C-Diff. Interventions included educate resident and responsible party on isolation precautions. On June 10, 2024 at 8:14 AM, V7 (LPN/Licensed Practical Nurse) was in R147's room with the door open, From the hallway V7 was seen standing next to R147's bed wearing gloves but had…

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 medications were obtained from the pharmacy in a timely manner to prevent residents from missing medication doses as ordered by the physician. This applies to 3 of 4 residents (R1, R2, and R4) reviewed for improper nursing care in the area of missing medication doses in the sample of 4. The findings include: 1. On April 22, 2024 at 2:20 PM, R1 said, I missed my morning dose of insulin (Humulin R U-500) on April 19, 2024. The evening of April 18, they ran out of the insulin and did not have enough to give me a full dose. On April 19, I was supposed to get a second dose at 2:00 PM and they still did not have the insulin in stock. It finally came at 3:00 PM that day. This happens every month. My blood sugars are all over the place and I should not be missing doses. They also ran out of my Vitamin D that I take once a month, and my depression medication. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with…

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 nebulizer treatments were completed and signed off on the medication administration record. This applies to 2 of 3 residents (R1, R10) reviewed for nebulizer treatments in the sample of 12. The findings include: 1. On 4/8/24 at 10:00 AM, V21 (R1's family) said on 3/28/24 at 6:00 PM, R1's breathing treatment mask was on the floor and the nebulizer machine was not on. R1's Facesheet dated 4/8/24 shows R1 is diagnosed with chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure . R1's Medication Administration Record (MAR) for March 2024 shows that R1 was to receive a treatment of Ipratropium-Albuterol via nebulizer on 3/28/24 at 6:00 AM related to chronic respiratory failure. There are no recorded nurse initials to indicate the medication was provided. 2. On 4/9/24 at 2:53 PM, R10 said that he is supposed to receive nebulizer treatments twice per day. R10 said that staff do not always make sure that he receives two treatments per day. R10's Facesheet dated 4/9/24 shows R10 has COPD. R10'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 notify a resident's POA (Power of Attorney) of changes in condition. This applies to 1 of 3 residents (R1) reviewed for policy and procedures. The findings include: On 02/08/24 at 1:00 PM, R1 was in her room in a wheelchair with her daughter at bedside. R1 was alert and confused. R1 said she previously had pneumonia and problems with her bladder. R1 said she was not sick for a long time before going to the hospital. On 02/08/24 at 12:10 PM, V3 (CNA/Certified Nursing Assistant) said she has been the CNA for R1 in the past and is taking care of her today. V3 said when R1 was coughing and had a loss of appetite last month, she reported it to the nurse. On 02/08/24 at 12:48 PM, V4 (LPN/Licensed Practical Nurse) said she takes care of R1 3 days a week. V4 said she was taking care of R1 when she became ill on 01/01/24. V4 said R1 was coughing. V4 said she completed a rapid Covid test on R1 and it was negative. V4 said she called the doctor and received orders for Claritin and Flonase. R1's 1/1/2024 progress notes…

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 reorder medications for residents to prevent missing doses of scheduled medications. The facility also failed to have two licensed professionals sign off the shift-to-shift controlled substance sheet and have two licensed professionals sign off on wasted controlled substances. This applies to 4 of 4 residents (R2, R3, R16, R17) reviewed for pharmacy services. The findings include: 1. On 12/20/23 at 02:26 PM, V20 (Family Member) said R3 missed three doses of the medication because they had run out of the Vimpat. R3's face sheet showed R3 was admitted to the facility with diagnoses including epilepsy, cognitive social or emotional deficit following cerebral infarction, muscle weakness, need for assistance with personal care, and peripheral vascular disease. R3's MDS (Minimum Data Set) dated 12/7/23 showed R3 was moderately impaired. R3 required set up assistance with eating, supervision for oral hygiene, moderate assistance for toileting hygiene, upper…

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 follow infection control measures for a resident during incontinence care, and residents under COVID-19 isolation. This applies to 5 of 7 residents (R11, R12, R15, R13, R14) reviewed for infection control. The findings include: 1. On 12/21/23 at 09:07 AM, V11 (CNA) provided incontinence care for R11. V11 removed R11's dirty brief and wiped R11's urine and stool. V11 did not change gloves or perform hand hygiene. V11 then grabbed R11's clean incontinence brief and incontinence pad and placed it under R11. V11 applied barrier cream using the same gloves. V11 secured the incontinence brief and placed the clean incontinence pad under the resident. The EMR (Electronic Medical Record) shows R11 was admitted with diagnoses including wedge compression fracture of T11-T12 vertebra, encephalopathy, Parkinson's disease, chronic obstructive pulmonary disease, muscle weakness, difficulty in walking, unsteadiness on feet, and lack of coordination.…

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 assistance to a resident for ADLs (Activities of Daily Living). This applies to 1 of 1 resident (R11) reviewed for ADLs. The findings include: On 12/21/23 at 08:37 AM, V14 (Family Member) told V16 (LPN/Licensed Practical Nurse) she wanted R11 up and out of bed because it was not good for him to be laying down since he had pneumonia. At 08:41 AM, V14 said the staff do not come check on her husband often enough and he was waiting to get cleaned up. V14 said R11 was not able to move too much because of his weakness, and he also had COVID-19 and pneumonia. On 12/21/23 at 09:07 AM, V11 (CNA/Certified Nurse Assistant) went into R11's room to provide incontinence care. R11 was laying on his back. When V11 removed R11's incontinence brief, there was urine and stool in the brief. R11's skin around his perineal area was excoriated and red. When V11 rolled R11 to the side to provide pericare, R11's buttocks and sacrum were excoriated and between shades of red and purple. When V11 was wiping R11, R11 began…

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 and administer a hospital discharge order for Quetiapine Fumarate for a resident. The facility also failed to ensure a resident had her narcotic available to prevent a resident from experiencing pain. This applies to 2 of 2 residents (R1, R2) reviewed for pharmacy services. The findings include: 1. On 11/9/23 at 12:15 PM, V3 (Family Member) said R1 was hospitalized and discharged back to the facility on [DATE]. V3 said she had reviewed the discharge paperwork from the hospital with V2 (DON) on 10/20/23 and was assured the order for Quetiapine Fumarate 25 mg (Milligrams) was on the discharge paperwork from the hospital. V3 said R1 was hospitalized again at the beginning of November, and she found out from the hospital staff that R1 did not have orders for Quetiapine Fumarate in the transfer paperwork from the facility. V3 said she called the facility and asked the staff about R1's Quetiapine Fumarate, to which they said there were no orders…

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 residents on a pureed diet were served a full serving of pureed pork and a dinner roll at the noon meal. The facility also failed to ensure residents were served the full serving of vegetables. This applies to 7 of 29 residents (R35, R43, R79, R133, R85, R99 & R22) reviewed for following menus in the sample of 29. The findings include: The facility's Spring/Summer Regular Menu 2023 for Monday August 28, 2023 shows, marinated pork loin, mashed potatoes, zucchini & tomatoes, dinner roll or bread, margarine, pineapple tidbits, beverage of choice. 1. On August 28, 2023 at the noon meal, V14 Dietary Aide and V13 Food Service Director (FSD) were serving the residents the noon meal on the second floor. They served the puree pork using a beige # 10 scoop size (3 ounces). The puree residents (R35, R43, R79 & R133) did not receive a roll or any type of bread. They only received pureed pork, pureed vegetable, mashed potatoes and pureed soup. The facility's resident's with a pureed diet texture list provided on…

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

Based on observation, interview and record review the facility failed to feed a resident in a dignified manner. This applies to 1 of 29 residents (R79) reviewed for dignity in the sample of 29. The findings include: On August 28, 2023 at 12:24 PM, V3 Certified Nursing Assistant (CNA) was feeding R79 the noon meal. R79 was sitting in a reclining wheelchair. V3 was standing next to R79 feeding her the meal. On August 30, 2023 at 10:29 AM, V8 Nurse Consultant stated, CNA's should not be standing to feed residents. The Illinois Long-Term Care Ombudsman Program Residents' Rights for people in Long-Term Care Facilities (no date) shows, Your rights to dignity and respect: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on observation, interview, and record review the facility failed to follow a physician's order for the use of a brace to treat a fractured wrist for 1 of 29 residents (R16) reviewed for physician orders in the sample of 29. The findings include. R16's face sheet showed R16 had a closed displaced transverse fracture of the right radius and dementia. R16's Progress Note dated 8/17/23 showed R16 was seen by a hand surgeon for a fractured right wrist. The note indicated the fracture was going to be treated non-operatively with a brace. R16's Doctor Note dated 8/14/23 showed R16 had a distal radius fracture. R16 was to wear a brace at night and during the day for the fracture. The brace was to be removed for hygiene purpose and to work on gentle range of motion. R16's Order Summary Report showed an order for the brace to be on night and day. The brace could be removed for hygiene purpose and to work on gentle range of motion. On 8/28/23 at 10:00 AM, R16 was in her room sitting on the edge of her bed. R16 did not have the brace on her wrist. The brace was sitting on R16's bedside…

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 R30 was provided with fingernail care for 1 of 29 residents (R30) reviewed for Activity's of Daily Living in the sample of 29. The findings include: On 08/28/23 at 1:57 PM, R30's fingernails on the right and left hand extended past the tips of his fingers. There was a dark substance under R30's nails. On 08/28/23 at 1:57PM, R30 said, I do not recall having my fingernails cut at the facility. I have made requests.multiple requests to have my fingernails trimmed. As a [NAME] Belt in Judo, I have always maintained good grooming practices that include keeping my nails trimmed short. No one in the facility has ever assisted me in trimming my fingernails. On 08/29/23 at 1:06 PM, V10 CNA-Certified Nursing Assistant said, nail care is provided as needed. R30 is alert. He can tell us when his nails need to be trimmed. R30's Minimum Data Set, dated [DATE] shows, Personal Hygiene: Extensive assistance. R30's electronic medical record on…

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

Based on observation, interview, and record review the facility failed to implement R52's pressure reduction interventions for 1 of 5 residents (R52) reviewed for pressure ulcer prevention in the sample of 29. The findings include: On 08/29/23 at 10:40 AM, R52's right and left posterior heels were resting on the foam filled mattress. On 08/29/23 at 1:09 PM, V10 CNA-Certified Nursing Assistant said, R52 should have heels elevated, he spends most of his time in bed. On 08/29/23 at 1:18 PM, V12 Wound Care Nurse said, R52 is a high risk for pressure ulcer development. Heel elevation is to prevent pressure ulcer development. Elevating the heels off the bed helps to off load pressure. R52 does not have independent mobility in bed. R52's Pressure Ulcer Risk Scale dated 08/03/23 shows, high risk for pressure injury. R52's current Care Plan on 08/29/23 shows, R52 has potential for alteration in skin integrity. Goal: R52's Skin will remain intact through next review. Interventions: Elevate heels off bed. The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations…

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 medication was safely disposed of to prevent a resident from accessing the disposed medication. This applies to 1 of 29 residents (R118) reviewed for safety in the sample of 29. The findings include: R118's face sheet showed R118 had the diagnoses of restlessness, delusional disorders, dementia, and Alzheimer's. On 08/28/23 at 09:52 AM, R118 was in bed. Sitting on R118's bedside table was a cup of water. The cup was filled 1/3 of the way with water. Submerged in the water was a pill. The pill was red, transparent, and oval shaped. No staff were present in R118's room. R118 said she did not know what the pill was, where it came from, or if the pill was for her. On 08/28/23 at 10:14 AM, V6 (Licensed Practical Nurse- LPN) said R118 was not assessed to self administer medications. V6 said the cup and pill were disposed of in the garbage can in R118's room. According to V6, R118 removed the cup with the pill from the garbage can. V6 said R118 has a history of taking things out of the garbage. V6 said 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 a resident with chronic pain was provided ordered pain medication. This applies to 1 of 29 (R110) reviewed for pain in the sample of 29. The findings include: On 8/28/2023 at 12:38AM, R110 said she has generalized abdominal and stoma pain rating her pain 8 out of 10. R110 said she hasn't had her Dilaudid (Hydromorphone) pain medication for a few days. R110 said she has been receiving Tylenol but it does not work as well Dilaudid. R110 said she is upset about not having her Dilaudid. On 8/29/2023 at 1:20PM, V4 Licensed Practical Nurse (LPN) said R110 has an order for Dilaudid. V4 said the Dilaudid is not currently in stock. V4 said R110 last received Dilaudid on 8/22/2023. On 8/30/2023 at 9:40AM, R110 said she still had not received her Dilaudid for pain control. On 8/30/2023 at 10:58AM, V4 said R110 received Tylenol for pain this morning. V4 said R110's Dilaudid had not shown up to the facility from the pharmacy. V4 said R110 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 reviewed the facility failed to ensure a resident's pain medication was available. This applies to 1 of 29 (R110) reviewed for pharmacy services in the sample of 29. The findings include: On 8/28/2023 at 12:38AM, R110 said she has generalized abdominal and stoma pain rating her pain 8 out of 10. R110 said she hasn't had her Dilaudid (Hydromorphone) pain medication for a few days. R110 said the facility has issues with ordering her pain medication on time and she has gone without her ordered pain medication. R110 said she has been receiving Tylenol but it does not work as well Dilaudid. R110 said she is upset about not having her Dilaudid. On 8/30/2023 at 9:40AM, R110 said she still had not received her Dilaudid for pain control. R110 said she was told by facility staff pain medication would be available yesterday. R110 said the facility keeps blaming the pharmacy for the error. On 8/29/2023 at 1:49PM, V2 Director of Nursing (DON) said pain medication should be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents understood the arbitration agreement. This applies to 2 of 3 residents (R22 and R134) reviewed for arbitration agreements in the sample of 29. The findings include: 1. R22's face sheet shows, he was admitted to the facility on [DATE]. R22's Minimum Data Set, dated [DATE] shows, he is cognitively intact. R22's Arbitration Agreement dated April 18, 2023 shows, R22 signed the document as well as V15 Admissions Director. On August 30, 2023 at 11:06 AM, R22 stated, he didn't remember signing the arbitration agreement. He didn't remember them going over what it was. He didn't even know what it was. He stated, if they had gone over it with him, he would have not signed it. 2. R134's face sheet shows, he was admitted to the facility on [DATE]. R134's Minimum Data Set, dated [DATE] shows, he is cognitively intact. R134's Arbitration Agreement dated May 9, 2023 shows, R134 signed the document as well as V15 Admissions Director. On August 30, 2023…

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 offered the pneumococcal vaccine. This applies to 3 of 5 residents (R66, R35, R392) reviewed for immunizations in the sample of 29. The findings include: 1. R66's face sheet shows, she was admitted to the facility on [DATE] and she is [AGE] years old. R66's immunization report shows, she received a pneumovax on September 25, 2020. The report does not show which pneumovax she received just that she received one. The same report also shows, Prevnar 13 as not eligible and Prevnar 23 (hx (history)) with a date of October 2, 2019. 2. R35's face sheet shows, she was admitted to the facility on [DATE] and she is [AGE] years old. R35's face sheet lists her diagnoses to include: chronic kidney disease and type II diabetes mellitus. R35's immunization report shows, Pneumovax 23 (hx) with October 23, 2013 and June 21, 2018 dates. There is no other documentation of another pneumococcal vaccine given. 3. R392's face sheet shows, he 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 administer medications at ordered times. There were 31 opportunities with 4 errors resulting in a 12.9% medication error rate. This applies to 2 of 5 residents (R2,R6) observed in the medication pass. 1) R2's electronic face sheet printed on 8/24/23 showed R2 has diagnoses including but not limited to chronic kidney disease stage 2, major depressive disorder, anxiety disorder, hypertensive heart and chronic kidney disease with heart failure, and long term use of anticoagulants. R2's medication administration record (MAR) for August 2023 showed R2 is to receive Flecainide Acetate 100mg and Apixaban 5mg every 12 hours at 9:00AM and 9:00PM. On 8/24/23 at 10:32AM, V4 (Registered Nurse) administered R2's Flecainide Acetate and Apixaban. (1 hour and 32 minutes past the scheduled administration time). On 8/24/23 at 10:37AM, V4 stated medications are considered late and a medication error if given over an hour beyond the scheduled administration time. V4 stated her medication pass for the morning is very heavy and…

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

Based on observation, interview and record review the facility failed to ensure residents received their medications at the ordered time for 4 of 4 residents (R2, R5, R7 and R8) observed during the medication pass. There were 29 opportunities with 13 errors resulting in a 44.82% error rate. The findings include: 1. R7's August Medication Administration Record (MAR) shows orders for acetaminophen 325 milligrams (mg), 2 tablets by mouth every 12 hours for pain management scheduled at 9:00 AM and 9:00 PM and lorazepam, 0.5 mg by mouth two times a day related to anxiety scheduled at 9:00 AM and 5:00 PM. On 8/17/23 at 11:55 AM, V5 (Licensed Practical Nurse) administered R7 her 9:00 AM dose of acetaminophen and lorazepam. 2. R8's August MAR shows orders for baclofen 10 mg two times a day for muscle spasms scheduled at 9:00 AM and 5:00 PM, fluticasone propionate nasal spray twice a day for allergy symptoms scheduled at 9:00 AM and 5:00 PM, metoprolol tartrate 12.5 mg two times a day for hypertension scheduled for 9:00 AM and 5:00 PM and sodium chloride 2 grams twice a day for cardio…

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 immediately report an alleged allegation of abuse to the State Survey Agency. This applies to 1 of 8 residents (R3) reviewed for abuse in the sample of 11. The findings include: R3's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including congestive heart failure, type 2 diabetes, osteoarthritis, atrial flutter, cardiomyopathy, peripheral vascular disease, and neuropathy. R3's Initial Nursing assessment dated [DATE] shows she's alert to person, time and place, clear speech, and has weakness to both lower extremities. On 8/17/23 at 11:06 AM, R3 said she needs help moving her legs and has pinching sensations on her feet. Two nights ago (8/15/23) an African American male put his lips on me. He was trying to massage my legs and rubbing my forehead with his hands and kissing my forehead. I reported this to V14 (Certified Nursing Assistant) on 8/16/23. I wanted to call 911 but did not have my phone with me.…

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 immediately initiate an investigation after an alleged allegation of abuse was reported. This applies to 1 of 8 residents (R3) reviewed for abuse in the sample of 11. The findings include: R3's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including congestive heart failure, type 2 diabetes, osteoarthritis, atrial flutter, cardiomyopathy, peripheral vascular disease, and neuropathy. R3's Initial Nursing assessment dated [DATE] shows she's alert to person, time and place, clear speech, and has weakness to both lower extremities. On 8/17/23 at 11:06 AM, R3 said she needs help moving her legs and has pinching sensations on her feet. Two nights ago (8/15/23) an African American male put his lips on me. He was trying to massage my legs and then rubbing my forehead with his hands and kissing my forehead. I reported this to V14 (Certified Nursing Assistant) yesterday (8/16/23). She wanted to call 911 but did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement care plan interventions for 1 of 3 residents (R1) reviewed for care plans in the sample of 11. The findings include: R1's Minimum Data Set assessment dated [DATE] shows that his cognition is impaired. R1's current Care Plan shows, noted to resist care this is related to poor motivation. Interventions: Notify MD and family of medical noncompliance. R1's August Medication Administration Record shows that he refused his ordered ipratropium-albuterol nebulizer on 8/9/23 at 12:00 AM and 4:00 AM and on 8/18/23 at 8:00 PM, refused to apply his CPAP (Sleep apnea machine) on 8/20/23, refused his ordered guaifenesin on 8/17/23 at 11:00 AM and refused his sodium chloride nebulizer on 8/18/23 at 9:00 PM. R1's Progress Notes from 8/9, 8/17, 8/18 and 8/20/23 were reviewed. There was no documentation noted that R1's physician and family were notified of R1's refusals. There was notation on 8/17/23 that R1 spit out out his guaifenesin but no notation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who requires extensive assist received bathing and dressing assistance for 1 of 8 residents (R2) reviewed for activities of daily living in the sample of 11. The findings include: On 8/17/23 at 10:09 AM, R2 was lying in bed with a soiled gown. There was multiple dried food debris spots on her gown. Her long hair was slicked back and stringy. She said her gown has not been changed in two weeks and she does not receive her showers very often. My shower days are supposed to be on Monday and Friday and have not been getting them. I need staff assistance for showers and dressing. On 8/17/23 at 12:34 PM, V12 (LPN) said R2 is alert and oriented and needs assistance with bathing and dressing. She can not do that on her own. On 8/17/23 at 12:25 PM, V14 (Certified Nursing Assistant-CNA) said showers should be given twice a week. R2's face sheets shows she is a [AGE] year old female with diagnosis including Elhers-Danlos syndrome,…

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 their ordered medication and failed to ensure medications were accurately documented for 2 of 4 residents (R1 and R2) reviewed for medication administration in the sample of 11. The findings include: 1. R1's August Medication Administration Record shows an order for vancomycin 1.25 grams intravenously every 12 hours for pneumonia to be administered at 9:00 AM and 9:00 PM, sodium chloride nebulization solution 3% four times a day for chronic obstructive pulmonary disease at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM and an order for ipratropium-albuterol inhalation solution every 4 hours for hypertensive heart disease to be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. On 8/17/23 at 10:30 AM, R1 was sitting in his wheelchair at the nurses station. At 12:30 PM, R1 was in the dining room waiting for lunch. R1 appeared short of breath, was breathing loudly and was coughing. R1 was served lunch…

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 free from significant medication error. This applies to 1 of 4 residents (R2) reviewed for medications in the sample of 11. The findings include: R2's face sheets shows she is a [AGE] year old female with diagnosis including Elhers-Danlos syndrome, chronic pain, hypertension, spondylosis, and long term use of anticoagulants. R2's Minimum Data Set assessment dated [DATE] shows she's cognitively intact and has no rejection of cares. On 8/17/23 at 10:09 AM, R2 said she's supposed to get her blood thinner (Lovenox) twice a day and has not been receiving it as she should. She reported this to V2 (Director of Nursing) and her response was I highly doubt that. R2 said nothing was done. R2's Medication Administration Record (MAR) for August 2023 shows orders for Enoxaparin Sodium Injection (anticoagulant) inject 70 mg (milligrams) subcutaneously every 4 hours for DVT prophylaxis related to Elhers-Danlos syndrome. R2's MAR shows 7 out of 41…

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 received laboratory services as ordered for 1 of 3 residents (R1) reviewed for laboratory services in the sample of 11. The findings include: R1's Care Plan shows diagnoses to include: diabetes mellitus, heart failure, anemia, hypertensive heart disease, malnutrition, chronic respiratory failure, dementia, urinary tract infection, pneumonia, sepsis due to methicillin resistant staphylococcus auresus and chronic obstructive pulmonary disease. R1's Physician's Order Sheet shows an order dated 8/13/23 for a vancomycin trough, CBC (complete blood count) and CMP (complete metabolic panel) to start on 8/14/23. R1's order details report shows that the order was created on 8/13/23 at 7:04 PM by V3 (Licensed Practical Nurse). R1's electronic medical record shows that R1 did not receive a blood draw for the vancomycin trough, CBC or CMP until 8/15/23 at 12:21 PM. On 8/21/23 at 3:48 PM, V10 (Nurse Practitioner) said that V1 (Administrator) had called her on Sunday (8/13) to let her know that R1 did not receive his…

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 enhanced barrier precautions (EBP) were implemented when toileting a resident for 1 of 3 residents (R1) reviewed for infection control in the sample of 11. The findings include: R1's Physician's Order Sheet shows an active active order for EBP due to having an indwelling urinary catheter. R1's Minimum Data Set assessment dated [DATE] shows that he requires extensive assistance with transfers, toileting and personal hygiene. R1's room had a sign on the door showing that he is on EBP and providers and staff must: Wear gloves and gown for the following high-contact resident care activities: transferring, providing hygiene, changing brief or assisting with toileting. On 8/17/23 at 10:30 AM, V17 (Certified Nursing Assistant) brought R1 to the bathroom and assisted him with toileting. On 8/17/23 at 1:05 PM, V17 brought R1 to the bathroom and assisted him with toileting. V17 then brought R1 into his room and assisted him to get to bed. V17…

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 follow their policy by not ensuring staff wore proper PPE (Personal Protective Equipment) in resident areas. This has the potential to effect all residents in the facility. The findings include: The CMS 672 dated 9/13/22 shows 133 residents reside in the facility. On 9/13/22 at 11:17 AM, V15 (Certified Nurse Aide) was walking in the hall on the [NAME] unit while wearing an N95 mask. Both straps were wrapped around her head and below her ears. V16 (Activity Aide) was in the dining/lounge room on the [NAME] unit and was wearing an N95 mask with both straps below her ears. V16 was also wearing her eye goggles on top of her head. V16 was standing over and assisting multiple residents while the goggles were on top of her head. V16 was continually observed for 10 minutes with the goggles remaining on top of her head. At 12:09 PM, V16 was still wearing the goggles on top of her head. At 1:43 PM, V15 and V16 were both wearing the N95 masks with…

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 at high risk for falls, failed to modify fall prevention interventions after a fall, and failed to ensure a resident was transferred in a safe manner for two of two residents (R329, R112) reviewed for safety and supervision in the sample of 26. The findings include: 1. R329's face sheet showed an [AGE] year old female with diagnosis of intracerebral hemorrhage, atrial fibrillation, urinary tract infection, dysphagia, aphasia, gastrostomy, and multiple unstageable pressure injuries. On 9/15/22 at 12:15 PM, R329 was seen laying halfway down in her bed. Her right arm was contracted at the elbow. R329 could not communicate or answer with a nod appropriately to questions. R329 had good eye contact during interactions but could not participate. On 09/15/22 at 09:17 AM, V9 Certified Nursing Assistant (CNA) said R329 is nonverbal and frustrated. She cannot communicate, gets antsy and frustrated all the time. It's hard to keep…

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 catheter care was performed in a manner to prevent cross contamination, failed to keep a urinary drainage bag below the bladder, and failed to ensure catheter tubing was secure for three of six residents (R121, R329, R112) reviewed for catheters in a sample of 26. The findings include: 1. R121's face sheet printed on 9/14/22 shows diagnoses including but not limited to obstructive uropathy, chronic kidney disease, and heart disease. R121's facility assessment dated [DATE] shows moderate cognitive impairment and requires extensive staff assistance with toilet use and personal hygiene. The same assessment shows R121 uses a urinary catheter and is frequently incontinent of bowel. R121's care plan shows a focus area start dated 8/22/22 related to urinary tract infections. R121's September 2022 physician order report shows an order dated 9/5/22 for an indwelling urinary catheter due to retention. The same report shows orders dated 9/5/22…

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 dietary recommendations were implemented for a resident with significant weight loss for one of three residents (R121) reviewed for weight in the sample of 26. The findings include: R121's face sheet printed on 9/14/22 shows diagnoses including but not limited to chronic kidney disease, heart disease, diabetes mellitus, dementia, and uropathy. R121's facility assessment dated [DATE] shows moderate cognitive impairment and requires staff assistance with eating. R121's face sheet shows an original admission date of 5/25/22 and a readmission date of 9/5/22. Progress notes show R121 was at the hospital 9/2 to 9/5 for syncope and collapse. R121's September 2022 physician order report showed orders dated 9/5/22 for regular texture diet with no added salt or concentrated sweets. The report showed orders dated 9/5/22 for: Monthly weight and record. There were no current orders for a nutritional supplement. On 9/13/22 at 1:51 PM, R121 way…

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 pause a tube feeding while repositioning a resident at risk for aspiration. This applies to one of three residents (R105) in the sample of 26 reviewed for feeding tubes. The findings include: The facility face sheet for R105 shows diagnoses to include amyotrophic lateral sclerosis, chronic obstructive pulmonary disease and dysphagia. The facility assessment dated [DATE] shows R105 to be cognitively intact and requires extensive assistance of two staff for bed mobility. On 9/13/2022 at 10:15 AM, V3 Director of Nursing (DON) and V17 wound care technician were observed repositioning R105. R105's tube feeding was infusing by pump into R 105's gastrostomy tube as V3 and V17 laid the head of the bed flat. On 9/15/22 at 10:33 AM, V19 Licensed Practical Nurse (LPN) said when R105 is going to have the head of his bed lowered the tube feeding should be paused to prevent aspiration. On 9/15/22 at 10:49 AM, V3 DON said a tube feeding needs to be put 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 the IV (intravenous) central line dressing was clean, dry, and intact for 1 of 1 resident (R93) reviewed for central line dressings in the sample of 26. The findings include: 1. R93's face sheet showed his initial admission to the facility was on 08/09/22 with diagnoses to include acute osteomyelitis right ankle and foot, Type 2 Diabetes Mellitus with diabetic neuropathy unspecified, encounter for orthopedic aftercare following surgical amputation, local infection of the skin and subcutaneous tissue unspecified. R93's facility assessment dated [DATE] showed he has no cognitive impairment (Brief Interview for Mental Status Score 13), requires limited assistance of one staff for transfer and locomotion, and he is on IV medications. R93's POS (Physician Order Sheet) shows an order for 'Transparent dressing - site visible (peripheral) Q72H (every 72 hours) with site change & PRN (as needed); midline, midclavicular and CVAD (central…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to assess effectiveness of pain medication in 1 of 3 residents (R327) reviewed for pain in the sample 26. The findings include: 1. R327's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include multiple sclerosis, covid-19, chronic diastolic heart failure, type 2 diabetes mellitus, and spondylopathy lumbar region. R327's POS (Physician Order Sheet) shows Acetaminophen 325 mg, give 2 tablet by mouth every 6 hours as needed for pain management. R327's Care Plan shows that R327 has 'Alteration in comfort . with a goal of 'indicators of discomfort . eliminated or decreased' and intervention of ' . observe resident for effectiveness of pain relief'. On 9/13/22 at 11:10 AM, observed R327 sitting up on bed eating her breakfast. R327 stated that she has pain at 10/10. The MAR (Medication Administration Record) for September 2022 shows that R327 received Acetaminophen 325 mg, 2 tablets, by mouth at on 9/12/22 at 01:26…

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.