Pearl Of Naperville, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance to residents with ADLs (Activities of Daily Living), specifically incontinence care and bathing, in accordance with resident needs and as outlined in their policy. This applies to 4 of 4 residents (R1, R3, R5 and R6) reviewed for ADL care in the sample of 6. The findings include: 1). R6's EMR (Electronic Medical Record) showed R6 was admitted to the facility on [DATE], with multiple diagnoses including encounter for orthopedic after care following surgical amputation, type 2 diabetes with foot ulcer, acquired absence of left above knee, peripheral vascular disease, obstructive sleep apnea, and other disorders of the nervous system. R6's MDS (Minimum Data Set), dated January 6, 2025, showed R6 was cognitively intact and required assistance with ADLs including set up assistance with eating, and oral hygiene, supervision with personal hygiene, substantial assistance with bathing, and dependent on staff with lower body…

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 provide staff in sufficient quantity to meet the residents' bathing, incontinence, and mobility care needs, and ensure timely answering of call lights during the evening and night shifts. This applies to 4 of 5 residents (R1, R3, R5, R6) reviewed for ADL care in the sample of 6. The findings include: The Facility Data sheet completed by V1 (Administrator), dated January 31, 2025, showed the facility census was 87. The Resident Council Meeting Minutes of November 22, 2024, showed one member requested more staff were needed each shift. The minutes reflect V1's (Administrator) response indicated it was quality of staff not quantity of staff the facility was looking for. On January 31, 2025, at 12:50 PM, V4 (Staff Scheduler) stated the staffing pattern included CNAs (Certified Nursing Assistants) work 8-hour shifts, and Nurses work 12-hour shifts. V4 stated there are 3-4 scheduled CNAs for the overnight shift (10PM-6AM), and 5-6 CNAs scheduled for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an environment where residents are treated with dignity and respect and requests for care are honored. This applies to 2 of 3 residents (R1 and R3) reviewed for ADLs (Activities of Daily Living) in the sample of 6. The findings include: 1). The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnosis including ALS (Amyotrophic Lateral Sclerosis), ulcerative colitis, juvenile myoclonic epilepsy, benign prostatic hyperplasia without lower urinary tract symptoms, generalized anxiety disorder, and essential hypertension. R1's MDS (Minimum Data Set), dated January 1, 2025, showed R1 was cognitively intact and required assistance with ADLs partial assistance with eating, upper body dressing, and personal hygiene, substantial assistance with lower body dressing, bathing, tub transfer and toileting and dependent on staff for bed mobility and transfer. The mobility device is listed as a wheelchair. 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 administer medications as ordered by the physician. There were 27 opportunities with 3 medication errors resulting in a 11.11% medication error rate. This applies to 1 of 3 residents (R2) reviewed for medication administration in the sample of 3. The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, pulmonary hypertension, peripheral vascular disease, hypertensive chronic kidney disease, chronic pulmonary embolism, hypertension, and anemia. R2's medication care plan dated December 21, 2022, showed, [R2] is on diuretic therapy. The care plan continued to show multiple interventions dated December 21, 2022, including Administer diuretic medications as ordered by physician. Monitor for side effects and effectiveness every shift. R2's Order Summary Report, dated December 31, 2024, at 11:44 AM, showed an order, dated December 20,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate and report an allegation of potential abuse/neglect. This applies to 1 of 6 residents (R1) reviewed for potential abuse/neglect in the sample of 10. The findings include: The EMR (Electronic Medical Record) showed R1 is a [AGE] year-old with diagnoses of ALS (amyotrophic lateral scoliosis), gastroenteritis, colitis, epilepsy, BPH (benign prostatic hypertrophy), and lack of coordination. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set), dated August 24,2024, showed R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. The MDS also showed R1 requires substantial assistance from staff for ADL (Activities of Daily Living) including oral care, hygiene, and grooming. On September 30,2024 at 12:36 P.M., R1 stated V9 (CNA, Certified Nurse Assistant from staffing agency) was very rude and had refused to give care when asked. R1 stated this was reported immediately to (V4, ADON/Assistant Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinence care to dependent residents. This applies to 2 of 5 residents (R7 and R10) reviewed for incontinence care in the sample of 10. The Findings include: 1. R7 is an [AGE] year-old, with diagnoses including type 2 diabetes mellitus, osteoarthritis, bipolar disorder, anxiety disorder, dementia, stage 4 kidney disease and adult failure to thrive. R7 was admitted to the facility on [DATE]. R7's MDS (Minimum Data Set), dated March 3, 2024 and September 3, 2024 showed R7's cognition was severely impaired. The MDS showed R7 was dependent from staff for ADL (Activities of Daily Living) including toilet needs and hygiene. R7's care plan, dated September 3, 2024, showed R7 was incontinent of bladder and bowel elimination and requires assistance for toilet needs and hygiene. On September 30,2024, at 11:00 A.M., R7 was sitting in her wheelchair in her room. V7 and V17 (CNAs/Certified Nurse Assistants) assisted R7 to the bathroom. V7…

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 provide nutritional supplement to prevent weight loss to a resident who had history of significant weight loss. This applies to 1 of 3 residents (R1) reviewed for nutritional supplement in the sample of 10. The findings include: The EMR (Electronic Medical Record) showed R1 is a [AGE] year-old with diagnoses of ALS (amyotrophic lateral scoliosis), gastroenteritis, colitis, epilepsy, BPH (benign prostatic hypertrophy), and lack of coordination. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set), dated August 24,2024, showed R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. The MDS also showed R1 showed no negative behavior including verbal, physical threatening and had not rejected care. The POS (Physician Order Sheet) for the month of September 2024 showed a physician order, dated August 27, 2024, for High Calorie drink two times a day, nursing to give 237 ml-240 ml. with preferred flavor of vanilla…

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 physician orders to administer neuromuscular medication to a resident (R1) with diagnosis of ALS (amyotrophic lateral scoliosis) and a neuropathy pain medication to a resident (R2) with diagnosis of diabetic neuropathy. This applies to 2 of 2 residents (R1 and R2) reviewed for significant medications in the sample of 10. The findings include: 1. The EMR (Electronic Medical Record) showed R1 is a [AGE] year-old, with diagnoses of ALS, gastroenteritis, colitis, epilepsy, BPH (benign prostatic hypertrophy), and lack of coordination. R1 was admitted to the facility on [DATE]. R1's MDS (Minimum Data Set) assessment, dated August 24,2024, showed R1 was cognitively intact. R1's care plan, dated October 01, 2024, showed to administer R1's ALS' medication as ordered by the physician to address ALS disease process. The POS (Physician Order Sheet) for the month of September 2024 showed a physician order, dated August 18, 2024, for Riluzole 50 mg film…

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 that kitchen was maintain clean, foods were stored properly, and washed pans and buckets for beverages were air dried. This applies to 85 residents who receives meals prepared in the facility kitchen. The findings include: Facility provided information that the census on September 16, 2024, was 85 residents with 2 (two) residents on NPO (nothing by mouth) status. On September 16 ,2024, at 10:00 AM during the initial tour of the kitchen with V15 (Food Service Dietary Manager), the following were observed: -a Dietary Aide was washing dishes using the dish machine. The left side of the dish machine were clean dishes and right side were dirty dishes. The dish machine was entirely soiled with heavy buildup of greenish colored lime debris. The floor under the dish machine all the way to the opening of the sewage drain was a heavy buildup of black debris that looks like a mud puddle. The pipe that goes to the sewer drain that was exposed was rusted. V15 said they will clean the dish machine and use a lime…

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 their water management plan for Legionella. This applies to all 87 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated September 16, 2024, at 11:50 AM, showed the facility census was 87 residents. On September 18, 2024, at 9:02 AM, V18 (Maintenance Director) said he has been in charge of the monitoring for the water management plan for Legionella for about two months. V18 continued to say he is supposed to check water temperatures including the hot water tank weekly, but V18 has not started monitoring or logging the temperatures yet. V18 said chlorine testing of the water is supposed to be performed, but he has not started testing yet. V18 said the facility has two eye wash stations. V18 continued to say he has only cleaned and tested the eye wash stations to ensure the caps come off twice in the past two months. V18 said he does not flush the eye wash stations. On September 18, 2024, at 9:09 AM, in the laundry…

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 develop and implement a COVID-19 immunization policy for staff and residents. This applies to all 87 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated September 16, 2024 at 11:50 AM, showed the facility census was 87 residents. On September 16, 2024, at 10:00 AM, V1, Administrator, was requested to provide a COVID-19 immunization policy and procedure. As of September 19, 2024, at 3:00 PM, the facility had not provided a COVID-19 immunization policy and procedure despite multiple requests. The facility provided a policy titled COVID-19 Guidance, dated May 25, 2023, which showed .b. Vaccinations: Facility will encourage residents, staff, and families to remain up to date with COVID-19 vaccination, including all eligible booster doses. 4. Reporting of Staff and Resident COVID-19 Vaccinations and Testing: Facility will continue to report SARS-CoV-2 infection and vaccination data to the National Healthcare Safety Network (NHSN) Long-term…

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 provide re-screening of residents with serious mental illness as instructed on each of the residents Level I PASARR (Preadmission Screening and Resident Review), to ensure that residents are offered the most appropriate setting and services for their individual needs. This applies to 4 of 4 residents (R6, R50, R53, and R75) reviewed for PASARR in the sample of 18. The findings include: 1. R50 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, schizoaffective disorder, and anxiety disorder, based on the face sheet. R50's screening verification form, dated February 5, 2024, showed the resident was screened on January 16, 2024, and the screening indicated nursing facility services are appropriate. R50's PASARR level I screening, dated February 2, 2024, showed the resident had mental health disability, documenting the resident was diagnosed or suspected 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 assist residents identified as needing assistance with personal hygiene and grooming. This applies to 4 of 6 residents (R23, R28, R58 and R77) reviewed for ADL (activities of daily living) in the sample of 18. The findings include: 1. R23 had multiple diagnoses including cerebral infarction, neurologic neglect syndrome, Alzheimer's disease and dementia without behavioral disturbance, based on the face sheet. R23's quarterly MDS (minimum data set), dated June 27, 2024, showed the resident was severely impaired with cognitive skills for daily decision making. The same MDS showed the resident required assistance from staff with personal hygiene. R23's active care plan, initiated on April 22, 2022, showed the resident had ADL self-care performance deficit and decreased functional mobility. The same care plan showed multiple interventions including staff assistance with personal hygiene and to check nail length and trim and clean on bath day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a provider of a resident not receiving anticoagulant medication. This applies to 1 of 1 resident (R45) reviewed for provider notification in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R45 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, atrial fibrillation, and peripheral vascular disease. R45's anticoagulant care plan, revised on September 8, 2024, showed, The resident is on anticoagulant therapy (aspirin) for prophylaxis. On warfarin as ordered. The care plan continued to show multiple interventions, dated August 7, 2024, including, Administer anticoagulant as ordered by physician. Monitor for side effects and effectiveness every shift. R45's Order Audit Report, dated September 19, 2024, showed an order, dated August 10, 2024, for Rivaroxaban starter pack oral tablet therapy pack 15 and 20 mg (milligram), give 15 mg by mouth two times a day. R45's Order Audit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to residents who were receiving Medicare Part A Services in the facility. This applies to 2 of 3 residents (R76 and R392) reviewed for beneficiary notice in the sample of 18. The findings include: 1. R76's EMR (Electronic Medical Record) showed R76 was admitted to the facility on [DATE], with diagnoses that included other disorders of the nervous system, morbid obesity, vasculitis limited to the skin, polyneuropathy, and cellulitis of bilateral lower limbs. R76's SNF ABN (Skilled Nursing Facility Advance Beneficiary Notification) form showed R76's Medicare Part A skilled services started on February 24, 2024, and last covered day of Medicare Part A services was May 24, 2024. R76 was discharged from Medicare Part A services by the facility when the Medicare Part A services days were exhausted. The facility did not issue a NOMNC (Notice of Medicare Non- Coverage),…

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 provider orders to administer anticoagulant medication to a resident. This applies to 1 of 1 resident (R45) reviewed for significant medications in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R45 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction, atrial fibrillation, and peripheral vascular disease. R45's Order Audit Report ,dated September 19, 2024, showed an order, dated August 10, 2024, for Rivaroxaban starter pack oral tablet therapy pack 15 and 20 mg (milligram), give 15 mg by mouth two times a day. A progress note, dated August 10, 2024, at 5:03 PM, by V22 (RN/Registered Nurse) showed, Resident has returned from hospital in stable condition. New orders for oral antibiotic, [rivaroxaban], and losartan. All orders verified by [V8 (Nurse Practitioner)] . R45's anticoagulant care plan, revised on September 8, 2024, showed, The resident is on anticoagulant…

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 personal care to dependent residents. This applies to 6 of 7 residents (R2, R3, R4, R5, R6, and R7) reviewed for activities of daily (ADL) care in a sample of 7. The Findings Include: 1. R2 is a [AGE] year-old male with cognition intact as per the MDS (Minimum Data Set), dated 7/5/24. The MDS also documented R2 (deaf and blind) requires substantial assistance with toileting hygiene. On 8/17/24 at 10:25 AM, R2 was observed with a soaked incontinent brief with urine and feces. On 8/17/24 at 10:25 AM, V7 (Manager on Duty / MOD/Licensed Practical Nurse/LPN) stated, Our staff is supposed to check on residents every two hours and as needed. They are shorthanded today. A review of R2's incontinent care plan documents: Clean peri-area after each incontinent episode. 2. R3 is a [AGE] year-old female with mild cognitive impairment as per the MDS dated [DATE]. On 8/17/24 at 10:32 AM, R3 stated, I have been waiting for 30 minutes to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate staffing to meet the care needs of residents. Staffing was insufficient to provide residents with assistance in Activities of Daily Living. This applies to 6 of 7 residents (R2-R7) reviewed for staffing concerns in a sample of 7. Findings include: On 8/17/24 at 8:50 AM, V4 (Licensed Practical Nurse / LPN) stated, We have 80 residents in the building and only four nurses and four CNAs on the floor now. We need at least 5-6 CNAs to provide resident care. I heard another CNA is coming late, around 9:30 AM. CNAs work from 6:00 AM to 2:00 PM. 1.R2 is a [AGE] year-old male with cognition intact as per the MDS (Minimum Data Set) dated 7/5/24. The MDS also documented R2 (deaf and blind) requires substantial assistance with toileting hygiene. R2 was observed on 8/17/24 at 10:25 AM, with a soaked incontinent brief with urine and feces. On 8/17/24 at 10:25 AM, V7 (Manager on Duty / MOD/Licensed Practical Nurse/LPN) stated, Our staff…

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 medicated patch was removed before another medicated patch was applied to prevent potential overdose of the medication. This applies to 1 of 3 residents (R1) reviewed for application of medicated patch/gel in the sample of 5. The findings include: R1 had multiple diagnoses including end stage renal disease, type 2 diabetes mellitus with diabetic chronic kidney disease, with diabetic nephropathy and with hyperglycemia, dementia without behavioral, psychotic, and mood disturbance and anxiety, based on the face sheet. R1's quarterly MDS (Minimum Data Set), dated July 3, 2024, showed the resident is severely impaired with cognition and required maximum assistance with most of her ADLs (activities of daily living). R1's order summary report showed multiple orders including hospice care, dated March 10, 2024, and Scopolamine transdermal patch, 1 mg (milligram) to be applied at bedtime, every three days for secretions, dated June 26, 2024. On July 29, 2024 at 4:53 PM, V7 (LPN/Licensed Practical Nurse) stated when V5…

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

Based on interview and record review, the facility failed to discontinue the resident's IV (Intravenous) catheter as ordered, and failed to ensure that maintenance care of the IV catheter was performed and documented. This applies to 1 of 3 residents (R1) reviewed for IV (intravenous) catheter in the sample of 5. The findings include: R1 had multiple diagnoses including end stage renal disease, type 2 diabetes mellitus with diabetic chronic kidney disease, with diabetic nephropathy and with hyperglycemia, dementia without behavioral, psychotic, and mood disturbance and anxiety, based on the face sheet. R1's quarterly MDS (Minimum Data Set), dated July 3, 2024, showed the resident is severely impaired with cognition and required maximum assistance with most of her ADLs (activities of daily living). R1's progress notes, dated May 22, 2024 at 1:23 PM created by V16 (Nurse Practitioner), showed R1 was on hospice care with significant history of CKD (chronic kidney disease) and CHF (congestive heart failure). It was documented R1's labs showed AKI (acute kidney injury) on CKD. 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 provide timely incontinent care to dependent residents. This applies to 3 of 4 residents (R2, R3, and R4) reviewed for activities of daily (ADL) care in a sample of 5. The Findings Include: 1. R2 is an [AGE] year-old female with severely impaired cognition as per the Minimum Data Set (MDS) Assessment, dated 2/23/24, and dependent on toileting hygiene. On 5/18/24 at 10:20 AM, R2 was in her bed, totally confused, and with a urine smell. On 5/18/24 at 10:22 AM, V12 (Certified Nursing Assistant/CNA) checked R2's incontinent brief and observed R2 with urine-soaked incontinent brief and discoloration from prolonged wetness. On 5/18/24 at 10:20 AM, V12 stated, I am not her assigned CNA, and I am unsure who is assigned to (R2). I am going to change her now. A review of R2's incontinent care plan document: Provide peri care after each incontinent episode. 2. R3 is a [AGE] year-old female with moderate cognitive impairment as per the MDS 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate and revise fall care plans as per their fall policy and procedure. This applies to 2 of the 3 residents reviewed (R1 and R2) for fall in a sample of 5. The findings include: 1. R1 is a [AGE] year-old male with moderate cognitive impairment as per the MDS(Minimum Data Set) assessment dated [DATE]. R1 stated during interview of 5/18/2024 at 9:30AM, I fell numerous times, and one time they sent me to hospital. I didn't have any injury or fracture. A review of the facility's fall log documents R1 was noted to have a fall on 3/30/2024, 4/12/24, and 4/22/24. A review of the fall care plan documented the facility did not investigate and revise the fall care plan after the falls of 4/12/24 and 4/22/24. A review of the health status note, dated 4/12/24, documents R1 was sent out to a local hospital for further evaluation after the fall on 4/12/24, and he returned the same day with no injury/fracture. On 5/19/24 at 12:15 PM, V2 (Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and immediately report an allegation of abuse to the administrator and report to the state agency. This applies to 1 of 3 residents (R2) reviewed for abuse in the sample of 7. The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, bipolar disorder, anxiety, schizoaffective disorder, and major depressive disorder. R2's MDS (Minimum Data Set), dated February 1, 2024, showed R2 had moderate cognitive impairment. R2's trauma care plan, dated August 3, 2023, showed, Given my trauma history and health decline. I present with some risk for failure to thrive secondary to poor insight/awareness and making questionable decisions. I present with a compromised history, and I am observed/monitored to mitigate potential risk towards becoming a recipient or perpetrator of abuse/neglect or further trauma. I have a history of physical, emotional…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary fashion. This applies to all 73 residents who reside in the facility. The findings include: The facility Census and Condition of Residents form 671, dated 11/30/2023, documents there are 73 residents residing in the facility. On 11/28/23 at 10:46 AM, the oven's glass windows, the wire racks, and the bottom of the inside of the oven was covered in a brown substance along with cooked food debris. The stove top around the burners had a thick layer of a brown tarry substance that could be scraped up (with a pen). The dry wall, above a food preparation table, was damaged and sagging with an opening through the dry wall. In another part of the kitchen, there was a large vent that was covered in dust, along with the ceiling around the vent, which had dust suspended from the ceiling over another preparation table. The fluorescent light fixtures were covered in dust. On 11/28/23 at 11:15 AM, V13 (Cook) said, Sometimes liquid comes out of the hole in the…

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

Based on interview and record review, the facility failed to have a water management program for Legionella in place, and failed to wear proper PPE (Personal Protective Equipment) in isolation rooms. This applies to all 73 residents residing in the facility. The findings include: 1. The facility Census and Condition of Residents form 671, dated 11/30/2023, documents there are 73 residents residing in the facility. On 11/30/23 at 12:46 PM, V15 (Maintenance Director) said he is not aware of any water management plan other than having an outside company come in every 6 months to test the water for contaminant including Legionella. V15 said he has never been given any flow diagrams of the building where he can determine potential risk areas. V15 said he did not believe he was part of the water management team. On 11/30/23 at 1:13 PM, V1 (Administrator) indicated V15 was the Water Management Team. V1 did not mention anyone else. On 11/29/23 at 10:55 AM, V8, LPN (Licensed Practical Nurse) and IP (Infection Preventionist), said she is not part of any water management team that she knows…

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 physician prescribed medications were not left with a resident for 1 of 1 resident (R9) reviewed for self-administration of medications in the sample of 19. The findings include: R9's face sheet, printed on 11/30/23, showed diagnoses including but not limited to dementia, cerebral infarction, kidney disease, heart failure, chronic obstructive pulmonary disease, and chronic rhinitis. R9's facility assessment, dated 9/15/23, showed severe cognitive impairment. The same assessment showed R9 has disorganized thinking and displays behaviors of yelling out and rejection of care. On 11/28/23 at 12:39 PM, R9 was seated in a wheelchair and alone in her room. R9 said she has skin issues on her sides and stomach. R9 stated she uses a powder on her skin to help it. R9 said the powder is kept in her top drawer of the bedside table. R9's drawer was opened, and a half medication cup of white powder was inside. A box labeled ipratropium bromide 0.03% (inhaler medication) and a second labeled fluticasone propionate…

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 pressure relieving mattress was set to meet the resident's needs were in place for 1 of 4 residents (R35) reviewed for pressure in the sample of 19. The findings include: R35's face sheet, printed on 11/30/23, showed diagnoses including but not limited to cerebral atherosclerosis, malnutrition, acute kidney failure, and prostate cancer. R35's facility assessment, dated 9/22/23, showed severe cognitive impairment, extensive staff assistance for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. The same assessment showed R35 is always incontinent of urine and bowel. R35's wound assessment, dated 11/28/23, showed bilateral MASD (moisture-associated skin damage) to the buttocks measuring 6.20 x 8.10 x 0.10 centimeters (length x width x depth). R35's pressure ulcer risk assessment, dated 11/22/23, showed a high risk of additional skin breakdown. R35's care plan showed a focus area, start dated 11/14/23, related to actual impairment to skin integrity of the bilateral buttocks 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate pain relief for 1 of 2 residents (R224) reviewed for pain in the sample of 19. The findings include: R224's face sheet showed she was admitted to the facility on [DATE], with diagnoses to include displaced fracture of medial malleolus of right tibia, fracture of lower end of right ulna, fracture of the lower end of right radius, fracture of fifth metacarpal bond right hand, fracture of fourth metacarpal bone left hand, and contusion of abdominal wall. R224's facility assessment, dated 11/18/23, showed she had no cognitive impairment. R224's care plan, initiated 11/16/23, showed, The resident has acute/chronic pain related to MVC - motor vehicle crash, multiple trauma, multiple fractures, right open distal radius and ulnar fracture and right fourth finger metacarpal fracture, s/p (status post) ORIF (open reduction and internal fixation) right wrist (11/6/23), left fourth metacarpal fracture, right medial malleolus…

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 medication was available from pharmacy for 1 of 1 residents (R226) reviewed for pharmacy services. The findings include: R226's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include collapsed vertebra, pressure ulcer of sacral region, protein calorie malnutrition, anemia, hypo-osmolality and hyponatriemia, chronic kidney disease, and dysphagia. R226's care plan, initiated 11/21/23, showed, The resident has anemia Give medications as ordered . R226's November 2023 eMAR (electronic Medication Administration Record) showed an order, dated 11/19/23, for Epoetin Alfa Injection to be given three times weekly for anemia. The same order was entered and discontinued on the same day. The same November 2023 eMAR showed a new order, entered 11/21/23, for Retacrit 2000 Unit/ml to be given by injection three times weekly for anemia. R226's November 2023 eMAR showed no doses had been administered since admission (4 missed…

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 received CPAP/BiPAP (Continuous Positive Airway Pressure/BiLevel Positive Airway Pressure) as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 3. 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 October 8, 2023, after R1 complained of feeling short of breath. R1 was admitted to the local hospital with a diagnosis of sepsis and pneumonia. R1 did not return to the facility. The EMR documents R1 had multiple diagnoses including acute and chronic respiratory failure, acute pulmonary edema, COPD (Chronic Obstructive Pulmonary Disease), diabetes, morbid obesity, kidney transplant, dysphagia, lack of coordination, heart failure, acute kidney failure, encephalopathy, syncope and collapse, oxygen dependence, chronic atrial fibrillation, and lymphedema. R1'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, the facility failed to ensure fall interventions were implemented for a resident with a history of falls. This applies to 1 of 3 residents (R2) reviewed for falls. Findings Include: R2's Face Sheet showed R2 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R2's 11/9/23 MDS (Minimum Data Set) showed R2 has severely impaired cognition. R2's listed diagnoses include fetal alcohol syndrome, dementia, Tourette's disorder, unspecified hearing loss, psychotic disturbance, and unspecified forms of tremor. R2's records indicated R2 had two different falls at the facility since admission, and both falls were unwitnessed with no pain or injury. One fall was on 11/9/23 at 4:00 AM, where the nurse noted R2 kneeling on the floor mat. R2's first fall was on 11/3/23 at 4:54 PM (the day of admission) when he was observed on the floor. R2's updated Care plan on 11/9/23 indicated R2 had an actual fall, and was high risk for falls. Interventions showed to…

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