Meadowbrook Manor - Naperville

Based on interview and record review, the facility failed to assist a resident with his social services needs. This applies to 1 out of 3 residents (R4) reviewed for social service needs. The findings include: On 6/30/2025 at 1:10 PM, R4 was fatigued in bed. R4 at times during the interview became frustrated and showed signs of impaired memory. R4 said V8 (Family Member) was no longer his Power of Attorney (POA) for health and finance. R4 said he believed V7 (Family Member) was now his assigned POA for health and finance. On 6/30/2025 at 10:45 AM, V2 (Director of Nursing/DON) said on 4/23/2025, V7 (R4's Family Member) called informing the facility that R4 was seeking legal aid to assist him in revoking his POA and divorce from V8. V2 said she informed V3 (Social Services/SS). On 6/30/2025 at 2:30 PM, V3 (SS) said residents were provided with social services, and if needed outside, referrals were made. V3 said R4 was a long-term care resident at the facility. V3 said she followed up with R4 on 4/25/2025, and he verbally revoked his financial and health POA from V8. V3 said 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.

Based on interview and record review, the facility failed to follow insulin administration instructions for a diabetic resident. As a result of this failure, R4 had an acute episode of hypoglycemia, which required the administration of emergency reversal-medications by emergency paramedics. This applies to 1 out of 3 residents (R4) reviewed for diabetes management. The findings include: On 6/30/2025 at 11:45 AM, V11 (Nurse) said she administered R4's scheduled insulin on 6/17/2025. V11 said insulin was administered based on the order. V11 continued to say that if a resident refuses to eat, they should not receive their fast-acting insulin because their blood sugar would drop. V11 said she believed residents with diabetes required an active order for emergency glucagon for emergency episodes of hypoglycemia. On 6/30/2025 at 12 PM, V18 (Certified Nurse Assistant/CNA) said on 6/17/2025, R4 refused his breakfast and lunch meals. V18 said she was concerned R4's blood sugar would drop and informed the nurse on duty and V18 documented R4's meal refusals. On 6/30/2024 at 11:50 AM, V12…

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 use a two-person transfer with a gait belt, as shown in the EMR (Electronic Medical Record), for a resident with a history of multiple falls. This applies to 1 of 3 residents (R2) reviewed for accidents and supervision in the sample of 3. The findings include: On June 12, 2025, at 11:21 AM, V3 (CNA-Certified Nursing Assistant) transferred R2 from the wheelchair to the toilet. No other staff were present. V3 said R2 was wearing regular socks and did not have shoes. V3 tightly held R2's waist band of her pants and R2's incontinence brief to lift the resident from the wheelchair to the toilet. V3 did not use a gait belt. As V3 was attempting to stand R2, R2's knees were buckling and R2 was unable to bear her full weight as she was being transferred to the toilet. R2 was unable to follow V3's instructions due to her cognitive status. V3 said R2 needed a new incontinence brief due to R2's previous incontinence brief being torn after it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy to ensure residents received timely incontinence care, showers, oral care, and assistance with shaving. This failure applies to 5 of 6 residents (R1, R2, R3, R5, and R6) reviewed for assistance with ADLs (Activities of Daily Living) in the sample of 6. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on January 2, 2025 and returned to the facility on January 9, 2025. R1 has multiple diagnoses including, acute encephalopathy due to sepsis, acute respiratory failure with hypoxia, diabetes, multiple sclerosis, paraplegia, major depressive disorder, PVD (Peripheral Vascular Disease), heart disease, idiopathic neuropathy, cognitive communication deficit, dysphagia, severe sepsis with septic shock, pneumonitis due to inhalation of food and vomit, hydronephrosis, Stage 4 pressure ulcer of the sacral region,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to immediately notify a resident's representative when a resident had a change in condition requiring transfer to the local hospital. This applies to 1 of 3 residents (R1) reviewed for change in condition notification in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on January 2, 2025, and returned to the facility on January 9, 2025. R1 has multiple diagnoses including, acute encephalopathy due to sepsis, acute respiratory failure with hypoxia, diabetes, multiple sclerosis, paraplegia, major depressive disorder, PVD (Peripheral Vascular Disease), heart disease, idiopathic neuropathy, cognitive communication deficit, dysphagia, severe sepsis with septic shock, pneumonitis due to inhalation of food and vomit, hydronephrosis, Stage 4 pressure ulcer of the sacral region, weakness, dementia, hearing…

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 the facility failed to ensure that sanitary practices are maintained to prevent cross contamination during dishwashing procedure and storage of dish rags. This applies to 199 residents that receive foods prepared and served from the facility kitchen. The findings include: The facility provided information that on October 7, 2024 the facility census was 203 residents with 4 residents on NPO (nothing by mouth) status. On October 7, 2024 at 9:20 AM, during initial tour of the kitchen, multiple rags that were both dry and wet/dirty were seen strewn on free standing carts. On October 7, 2024 at 9:24 AM, during the dishwashing procedure at the high temperature dish machine, V10 (Dietary Aide), who was wearing gloves, was observed washing and rinsing dirty dishes prior to loading them on racks to send through the dish machine for sanitation. V10 was then seen going to the clean side without changing her gloves or washing her hands and unloading cleaned water pitchers and a plate guard and put them away on a shelf. V11 (Dietary Aide) was seen walking in from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 7 of 7 residents (R29, R58, R129, R149, R152, R153 and R180) reviewed for ADL (activities of daily living) in the sample of 35. The findings include: 1. R29 had multiple diagnoses including dementia without behavioral disturbance and weakness, based on the face sheet. R29's admission MDS (minimum data set) dated September 27, 2024 showed that the resident was moderately impaired with cognitive skills for daily decision making and required substantial/maximum assistance with personal hygiene. On October 7, 2024 at 12:11 PM, R29 was eating inside the unit dining room. R29 was non-verbal. R29 had accumulation of facial hair above her upper lip. On October 8, 2024 at 10:20 AM, R29 was sitting in her wheelchair inside the unit dining room. R29 had accumulation of facial hair above her upper lip. V3 (Assistant Director of Nursing) was present…

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

Based on observation, interview and record review, the facility failed to label and date medications after it was opened to determine expiration dates and failed to remove expired medications from the medication carts. In addition, the facility failed to ensure that a narcotic with a broken package/container is discarded. This applies to 10 of 10 residents (R16, R27, R88, R106, R115, R129, R132, R146, R148, and R180) reviewed for medication storage in the sample of 35. The findings include: On October 09, 2024, from 10:59 AM through 12:16 PM, multiple medication carts were inspected with the corresponding nurses (V23, V29, V30, V31) assigned to each cart, and the following were observed. 1. R180's Insulin Glargine and Insulin Lispro were opened and not dated. 2. R27's Lantus Pen was opened and not dated. 3. R129's vial of Lispro has a label which shows that it was opened on 9/1/24 and expired on 10/1/24. 4. R16's Alprazolam 0.25 mg tab #25 container was torn open and taped over. 5. R148's Insulin Lispro has a label which shows that it was opened on 8/24/24 and expired on 9/23/24. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide wound treatment as ordered. This applies to 1 of 7 residents (R112) reviewed for pressure ulcer prevention and treatment in the sample of 35. This failure resulted in the worsening of an acquired pressure ulcer wound from a stage 2 to an unstageable wound. The findings include: R112's EMR (Electronic Medical Record) showed R112, was admitted to the facility on [DATE], with multiple diagnoses including unspecified dementia, age related osteoporosis, unspecified macular degeneration, cognitive communication deficit, adult failure to thrive and mild protein-calorie malnutrition. R112's MDS (Minimum Data Set) dated September 10, 2024, showed R112 had severe cognitive impairment and required assistance with ADLs (Activities of Daily Living) including substantial assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and bed mobility and was dependent on staff for transfer. R112's wound assessment dated…

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

Based on observation, interview and record review, the facility failed to apply a resting hand splint for a resident to prevent contractures. This applies to 1 of 4 residents (R155) reviewed for range of motion in the sample of 35. The findings include: R155's face sheet included diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations, cognitive communication deficit, spinal stenosis, site unspecified. R155's significant change MDS (minimum data set) dated August 30, 2024 included that R155 is cognitively intact and has upper extremity impairment on both sides. R155's care plan-initiated May 15, 2024 included that R155 requires splint to left hand related to further deterioration. Interventions for the same included to apply splint/brace to left hand. On AM/Off at lunch by the restorative nurse. R155's Physician Order Sheet showed Patient to wear left hand resting splint, on with morning ADL (activities of daily living) and off after lunch, off for hygiene, exercise and skin check every shift by nursing staff. On October 7, 2024 at 12:12 PM, R155 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe transfer for a resident who requires 2 staff assistance for transfer from one area to another. This applies to 1 of 3 residents (R99) reviewed for transfers in the sample of 35. The findings include: Face sheet shows R99 is 82 years-old who has multiple medical diagnoses which include Alzheimer's disease, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, encounter for palliative care. R99 is under hospice care. Minimum Data Set (MDS) dated [DATE], shows R99 is cognitively impaired and requires maximum assistance for activities of daily living (ADL) care. On October 7, 2024, at 11:18 AM, V7 (Hospice Certified Nursing Assistant/CNA) transferred R99 from bed to the reclining wheelchair via mechanical lift. V7 transferred R99 by himself (V7) without another staff to help him. On October 9, 2024, at 10:53 AM, V35 (Restorative Director) stated, there…

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 alternate meal with similar nutritive value as the main entrée for residents that had history of weight loss. This applies to 2 of 6 residents (R60, R152) reviewed for nutrition in the sample of 35. The findings include: Facility spread sheet for Week 2 Tuesday showed that the main meal for lunch consisted of Turkey Burger Patty Melt (1 portion=3 oz protein). On October 8, 2024 at 12:05 PM, V12 (Assistant Cook) stated that she prepared egg salad sandwich for the substitute menu and put 2 oz/ounce of egg salad per sandwich using a #16 scoop. The egg salad sandwiches that were already prepared appeared to have a thin layer of egg salad within each sandwich. Facility scoop guidance titled Disher Capacity showed that blue color #16 scoop =2.07 fluid oz. Recipe for Egg Salad Sandwich for 3 oz portion serving included to portion 2 #10 scoops of egg salad unto half of bread slices. Serve 1 sandwich (2 halves) with 2,#10 scoops of egg salad for 3 oz protein serving. 1. R152's face sheet included diagnoses…

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 follow physician's order during medication administration. There were 32 medication opportunities with 5 errors resulting to 15.63% medication error rate. This applies to 2 of 4 residents (R25 and R164) reviewed for medication administration in the sample of 35. The findings include: 1. On October 8, 2024, at 9:35 AM, V4 (Nurse) administered multiple medications to R25. Prior to the administration, V4 prepared the medications by putting it in the medication cup and identifying each medication and its dosage one of the medications and/or vitamins included was Vitamin D3 (Cholecalciferol). V4 said that she was giving one tablet of Vitamin D3 1000 units (IU) or 25 micrograms (mcg). V4 took one tablet of the Vitamin D3 from the container bottle in the cart and the bottle was labeled Vitamin D3 10mcg (400IU). R25's Medication Administration Record (MAR) for the month of October 2024, shows multiple medications scheduled for the morning which included Cholecalciferol 1000 units, Cyanocobalamin 1000 mcg, 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 follow infection control practices related to hand hygiene, removal of gown after leaving resident's bedroom, and disposal of soiled linen and gown. This applies to 3 of 35 residents (R25, R129, and R146) reviewed for infection control in the sample of 35. The findings include: 1. R25 is on EBP (Enhanced Barrier Precaution). On October 8, 2024, at 9:35 AM V4 (Nurse) administered intravenous (IV) medication to R25. Prior to administration, V4 donned isolation gown and gloves. After V4 administered the IV medication, V4 removed her gloves and left the bedroom still wearing the isolation gown. V4 went to the medication cart which was parked across the hallway from R25's bedroom, where V4 continued to prepare R125's oral medications. V4 re-entered R25's bedroom to administer the oral medications, while wearing the same gown. V4 came out again without removing the gown to write a label for the IV medication. When asked why she had not removed the gown, V4 said that that she was not yet done with R25. 2. On October…

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

Based on observation, interview, and record review, the facility failed to report allegations of resident abuse for 1 of 6 residents (R1) in the sample of 6 residents reviewed for abuse. The findings include: On 9/18/24 AT 10:00 AM, R1 was noted to have yellow/green bruising around her left eye orbit and a small purple mark under her left eye near her cheek bone. When asked what happened to her eye, R1 imitated a fist punching her in the left eye while saying the muchacho. R1 then became tearful and used a tissue to dab at her eyes. On 9/18/24 at 10:09 AM, V5, Licensed Practical Nurse (LPN), said if a resident had a new bruise, he would ask them what happened. He would ask the CNAs (certified nursing assistants) if they knew about any injuries to the resident. V5 said he would report it to the supervisor and the administrator. V5 said they would need to investigate it. V5 said the investigation would include interviewing staff from the present shift back 24-48 hours prior to find out if anything happened during care of the resident. They could review video to see if it would provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess and obtain treatment orders for a resident with a known surgical wound. This applies to 1 of 3 residents (R1) reviewed for quality of care. The findings include: R1's EMR (Electronic Medical Record) showed a readmission date of 8/05/2024. R1's EMR showed R1 had multiple diagnoses including left gluteal abscess, urinary tract infection, right arm deep vein thrombosis, metabolic encephalopathy, vascular dementia, morbid obesity, and malnutrition. R1's MDS (Minimum Data Set) dated 7/03/2024 showed R1 was incontinent of bowel and bladder and required substantial to maximal staff assistance with toileting hygiene. On 8/09/2024 at 12:30 PM, V10 (Certified Nurse Assistant/CNA) and V11 (Restorative Aide) were providing care to R1 and were asked to check R1's skin. V10 said R1 was readmitted with a wound to her left inner groin area that was not covered. R1 had an exposed open tunneling wound to her left inner gluteal fold area. R1's wound…

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 staff (V3, Registered Nurse) and (V16, CNA/Certified Nursing Assistant) failed to report an allegation of mistreatment and or potential sexual abuse to the administrator. This applies to one of nine residents (R1) reviewed for abuse in the sample of 12. The findings include: The EMR (Electronic Medical Record) showed that R1, an [AGE] year-old female, was admitted to the facility on [DATE]. R1's diagnoses included osteomyelitis of vertebra, lumbar region, spinal stenosis, COPD (chronic obstructive pulmonary disease), polyneuropathy, ASHD (atherosclerotic heart disease), depression, history of UTI (urinary tract infection), history of malignant neoplasm of uterus, and contact dermatitis. The MDS (Minimum Data Set) assessment dated [DATE] showed that R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. The MDS showed R1's functional status that she required moderate to extensive assistance with ADLs (Activities of Daily Living) 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 observations, interviews, and record reviews the facility failed to isolate to control the spread of a potential communicable disease for residents identified with suspicious rashes. This applies to 3 of 3 residents (R1-R3) reviewed for infection control practices. The finding includes: On 12/26/2023 at 10:46 AM, R1 was in bed, he said he was itchy. R1 had scattered dry spots on his left arm, right posterior thigh area, neck area, and left chest fold area. R1 said he saw the dermatologist and had a skin biopsy and does not know the results. R1 said the dermatologist ordered the cream and told him to shower. R1 said he was never isolated for his rash. R1 said his roommate R2 was also itchy. On 12/26/2023 at 11:00 AM, R2 was in bed covered with a blanket and scratching his leg underneath the blanket. R2 was non-interviewable. On 12/26/2023 at 1:10 PM, R3 was sitting in her wheelchair in her room (R3's room is accross R1 and R2's room). R3 said her rash was terrible and could not stop scratching. R3 said that when she's in therapy she needs to constantly stop to scratch. R3…

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 assess residents for self-administration of medications and, failed to obtain physician orders to have medications stored in resident rooms. This applies to 4 of 4 residents (R27, R67, R84 and R105) reviewed for medications in the sample of 73. The findings include: 1. On 10/31/23 at 10:23 AM, during initial tour rounds, R67 was resting in bed. R67 had a bottle of Miconazole nitrate 2% (antifungal powder) on her bedside table. R67 said she uses if for the rash under her arms. R67's current physician order sheet (POS) reviewed; R67 did not have an order for the antifungal powder or to self-administer medications. R67's care plan was reviewed, R67 was to care planned to self-administer medications. 2. On 10/31/23 at 11:12 AM, R27 was sitting by the side of her bed; R27 had Albuterol Sulfate HFA (hydrofluoroalkane) inhaler, Qvar redihaler (Beclomethasone Dipropionate HFA) breath activated inhaler aerosol on her bedside table. R27 had a clear plastic bag which had a glucometer, bottle insulin test strips, and six…

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 dignified care during medication administration and failed to promote dignity of a resident with indwelling catheter. This applies to 4 of 4 residents (R56, R138, R141 and R195) reviewed for dignity in a sample of 73. The findings include: 1. On 11/1/23 at 11:00 AM, V23 (Agency Registered Nurse) administered R56's G-Tube (Gastrostomy) medications in her room. R56's bed was close to the window; V23 failed to close R56's privacy curtain and close the door during the medication administration. R56 was visible from the hallway, and R164 (R56's roommate) was in the room during the g-tube medication administration. R56's face sheet (11/1/23) showed the following diagnoses of generalized idiopathic epilepsy and epileptic syndromes, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, adult failure to thrive. R56's MDS (Minimum Data Set) dated 9/6/23 shows that her cognition is moderately impaired. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have call lights accessible to dependent residents. This applies to 5 of 5 residents (R24, R26, R164, R175, and R184) reviewed for accommodation of needs in a sample of 73. The findings include: 1. On 10/31/23 at 11:54 AM, during initial tour rounds on the second floor, R175 was observed sitting in his wheelchair by the bedside. R175's call light could not be located. R175's face sheet (11/1/23) showed the following diagnoses of Parkinson's disease without dyskinesia, dementia, neuro cognitive disorder with Lewy bodies and history of falling. R175's MDS (Minimum Data Set) dated 9/18/23 showed that R175's cognition is severely impaired and needs extensive assistance with two or more person physical assist with toilet use. R175's care plan (revised on 9/22/23) is at risk for falls, with interventions to educate resident, family and care givers about safety reminders. 2. On 10/31/23 at 12:03 PM, R164 called out from her room and asked if…

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

Based on observation, interview and record review, the facility failed to maintain hazard free environment to residents. This applies to 5 of 5 residents (R27, R37, R157, R163 and R191) reviewed for accidents and supervision in a sample of 73. The findings include: 1. On 10/31/23 at 11:12 AM, R27 was sitting by the side of her bed. R27 had a clear plastic bag which had a glucometer, bottle insulin test strips, and six lancets on the dresser. On 11/1/23 at 9:22 AM, the glucometer, lancets, test strips were still on R27's dresser. On 11/2/23 at 9:10 AM, the glucometer, lancets, test strips were still on R27's dresser. R27 said she checks her glucose levels every night because her glucose levels runs high. There were no sharps container in R27's room; surveyor asked R27 where she disposes the used lancets, R27 pointed to the trash can by her bedside. R27's face sheet (11/1/23) showed the following diagnoses of Type 2 Diabetes Mellitus with hypoglycemia, Type 2 Diabetes Mellitus with other circulatory complications, chronic kidney disease, stage 3 and acquired absence of kidney. R27's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview and record review, facility failed to follow contact isolation precautions, follow appropriate hand hygiene, contain soiled linen and provide appropriate personal hygiene. This applies to 4 of 4 residents (R5, R111, R46 and R114) reviewed for infection control in a sample size of 73. Findings include: 1. R177's stool culture report dated 11/1/23 showed clostridium difficile toxin antigen positive. Progress notes dated 10/30/23 at 10:41 showed stool sample was collected, as R177 had diarrhea two times. On 10/31/23 at 10:53 AM, R177's room had a 'contact isolation' sign board outside his room and PPE (personal protective equipment) was available outside the room. R177 was sitting on his adult reclining chair in his room with two visitors at his bedside without PPE on. Visitors were seen to be touching the bed of R177. R177's face-sheet showed, R177 was admitted to the facility on [DATE] with diagnoses to include congestive heart failure, encephalopathy and Type 2 Diabetes Mellitus.…

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

Based on observations, interviews and s reviews, the facility failed to report and provide necessary care to 2 residents (R24, R46) who were reviewed for change in condition in a sample of 73. 1. On 10/31/23 R24, who has a history of coronary artery disease, hypertension, arrhythmia, atrial fibrillation, and a history of myocardial infarction, was observed in her bed reporting to have chest pain and her call light was not in reach. R24 said she had not called for help because she was unable to find her call light. The surveyor reported to R24's nurse V5, that R24 was complaining of chest pain. At 11:59am V5 came into R24's room and R24 told her she was having chest pain. V5 told her she would go get her some Tylenol for her pain and left R24's room. V5 did not assess R24's vital signs at that time. Then at 12:05pm V5 returned to R24's room and gave R24 the Tylenol but still did not take R24's vital signs. On 10/31/23 at 11:59am V5 was asked why she did not take R24's vital signs and she said because she complains of chest pain a lot and was sent out to the hospital in the past 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 implement interventions to prevent a resident from developing a pressure ulcer. This applies to 1 of 4 resident R115 reviewed for facility acquired pressure ulcers in a sample of 73 residents. Findings include: R115 was admitted to the facility on [DATE] with diagnoses that includes dementia, osteoporosis, dysphagia, and failure to thrive. R115 developed a stage 4 pressure ulcer 11 months after admission to the faciity. On 11/01/23 at 10:24 AM, wound care was observed. Due to R115's positioning and severity of the finger ontracture the wound was not visualized. When the soiled dressing was removed from R115 right hand and bright red blood was observed. V30 (Restorative Aid) stated R115 was supposed to have a rolled washcloth in her contracted hand at all times. V31 (Wound Nurse) stated R115 was admitted to the facility with contractures, but developed the right hand wound while in the facility. If R115 had a hand splint or rolled washcloth…

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 anti-contracture devices were applied as ordered. This applies to 1 of 16 residents (R195) reviewed for anti-contracture devices in a sample size of 73. The findings include: On 10/31/2023 at 10:54 AM, R195 was observed with his left hand in a fist position. R195 did not have a splint on. He said staff has not been applying his splint. A sign on top of his bed said R195 needs a splint on his left hand, on after breakfast and off before dinner. On 11/1/2023 at 11:10 AM, R195 was not wearing a splint on his left hand. On 11/1/2023 at 2:23 PM, R195 had no splint on his left hand. On 11/02/2023 at 9:12 AM, V21 (Restorative Director) said R195 needs to wear splint for stiffness on his left hand. V21 said if splint is not worn, the stiffness will get worse. R195 admission Records show R195 was admitted to the facility on [DATE]. R195's diagnoses included hemiplegia and hemiparesis affecting left nondominant side. R195's Physician Order…

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, interviews and record reviews, the facility failed to provide necessary catheter care in a timely manner to 1 of 3 residents (R46) reviewed for catheter care in a sample of 73. On 10/31/23 at 1:35pm V9 CNA (Certified Nurse's Assistant) was preparing R46 for a shower. V9 removed R46's brief and observed urine in his brief, R46 has an indwelling catheter. V9 told R46 that his catheter must be leaking, and she would tell his nurse. On 11/1/23 at 2:58pm a review of R46's electronic records did not show any documentation of a report that R46's catheter was leaking urine. On 11/2/23 at 9:38am V5 (Nurse) said that V9 never reported that R45's catheter was leaking. On 11/2/23 at 10:08am V5 checked R46's brief and observed urine in his brief. At 10:13am V5 said that she notified R46's Nurse Practitioner about the leaking catheter and was given orders to change the catheter. On 11/2/23 at 1:47pm, V2 DON said that if urine is observed in a brief of a person with a catheter, it should be reported. V2 said This should be done because the catheter could be damaged or kinked…

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 sanitary storage of respiratory equipment when not in use. This applies to 3 out of 4 (R5, R27, and R97) residents reviewed for use of respiratory equipment in the sample size of 73. 1. Different observations on 10/31/2023 at 11:03 AM and 11/1/2023 showed R97's firm plastic suction tip was not contained and was left on top of the suction machine. R97 had a decannulated tracheostomy with stoma open to air. On 11/2/2023 at 9:31 AM, V2 (DON-Director of Nursing) said respiratory equipment should be cleaned and contained in a bag for infection control. R97's admission Records show R97 was admitted on 8/ 16/2023. R97's diagnoses included malignant neoplasm of lung and larynx. Facility's Departmental (Respiratory Therapy) - Prevention of Infection Policy revised on November 2011 sated the following: . Purpose: The purpose of this procedure is to guide associated with respiratory tasks and equipment, including ventilators, among residents…

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.