Newman Rehab & Health Care Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide hygienic incontinence and urinary catheter care to prevent cross contamination for two (R12, R18) of four residents reviewed for urinary care in the sample list of 25. Findings include: 1.) R12's Minimum Data Set, dated [DATE] documents R12 has severe cognitive impairment, is always incontinent of bowel and bladder, and is dependent on staff assistance for toileting hygiene. On 9/16/24 at 2:33 PM V11 and V12 Certified Nursing Assistants transferred R12 into bed with a full mechanical lift and R12 was incontinent of urine. V12 provided R12's incontinence cares starting with R12's buttocks. V12 wiped R12's buttocks three times with wash cloths and bowel movement was visible on the cloths. V12 turned R12 onto R12's back, and used wash cloths to cleanse R12's frontal perineal area using the same gloves worn to cleanse R12's buttocks. V12 did not change gloves until after V12 applied R12's clean incontinence brief. On 9/16/24 at 2:49 PM…

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 facility policy and document/record the daily amount of enteral feeding administered to a resident for one of one resident (R18) reviewed for Gastrostomy tube feedings in the sample list of 25. Findings include: The facility's Enteral Feeding policy with a revised date of February/2008 documents, Purpose: To ensure a safe, nutritionally appropriate product which provides a source of complete nutrition in a form that will pass through a tube into the digestive system and which will maintain nutritional status as designated. 1. The Dietician/Consultant will monitor all diet orders for tube feedings and will recommend as appropriate changes in product according to resident need. 4. The fluid intake for the resident receiving a tube feeding should be equivalent to the fluid needs as assessed by the Dietician. Fluid need not be met by product alone in which case water flush ordered may be recommended to meet the needs of the tube fed resident. A record of daily intake of the tube feeding and the flushes 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 interview and record review the facility failed to obtain consents, complete assessments, document nonpharmacological interventions, develop a care plan and document stop dates for psychotropic medications for two (R10, R12) of six residents reviewed for unnecessary medications in the sample list of 25. Findings include: The facility's Psychotropic Medication Policy dated 12/30/13 documents to attempt to rule out social and environmental factors as causes for behaviors, initiate a Pre-Psychotropic Medication Assessment, attempt nonpharmacological interventions prior to prescribing psychotropic medications, and obtain consent for psychotropic medication use from the resident or resident representative. This policy documents psychotropic medication assessments will be completed at least quarterly, and psychotropic medication use, potential side effects and targeted behaviors will be included in the resident's plan of care. This policy does not address stop dates for psychotropic medications ordered 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.

Based on observation, interview and record review the facility failed to store and secure controlled medications behind a separately locked compartment for three (R10, R12 and R23) of three residents reviewed for medication storage from a total sample list of 25 residents. Findings include: The facility provided Procurement and Storage of Medications Policy date reviewed October 2006, documents that Schedule II drugs are to be stored under a double-lock subject to a different key. On 9/16/24 at 3:03PM, an unlocked refrigerator contained five bottles of Lorazepam (schedule IV controlled substance) 30 milliliters, with a concentration of 2 milligrams per milliliter. One bottle was documented for R23, three bottles were documented for R12 and one bottle was documented for R10. On 9/16/24 at 3:04PM, V3 Registered Nurse stated the refrigerator should have been locked because it had Lorazepam in it. On 9/16/24 at 3:06PM, V2 Director of Nursing observed that the refrigerator housing five bottles of Lorazepam was unlocked and confirmed that the refrigerator should have been locked.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to maintain documentation of COVID-19 vaccination for three (R9, R19, R36) of five residents reviewed for immunizations in the sample list of 25. Findings include: The facility's Immunization of Residents policy dated 5/19/23 documents the facility will offer immunizations to aid in preventing infectious diseases. This policy documents to offer the current recommended COVID-19 vaccine upon admission for residents who are not considered up to date with the vaccine, review consent forms to verify timing of previous vaccinations and document immunizations on the resident's Immunization Record. 1.) R9's Face Sheet documents R9 admitted to the facility on [DATE] and R9 is over age [AGE]. R9's Cumulative Diagnosis Log documents R9's diagnoses include Congestive Heart Failure, Coronary Artery Disease, and Type 2 Diabetes Mellitus. R9's COVID-19 Vaccination Record Card documents vaccine administrations on 2/4/21, 3/4/21, 11/4/21, and 6/29/22. There is no…

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 therapy services were provided for two (R1 and R3) of three residents reviewed for therapy services in the sample of three. Findings include: The facility's admission Packet (current) documents the following information: Dear Residents and Family Members: Our facility offers services that may be covered by the Medicare Program. These services include skilled nursing care, therapy services, pharmacy, and medical supplies. If you have Medicare benefits and you or a family member consents, we will bill the Medicare program for services that are rendered at this facility. 1. R1's Face Sheet (current) documents R1 being admitted to the facility on [DATE]. R1's Therapy Evaluation and Treatment order dated 1/22/24 per Physician Order Sheet (POS) documents R1 is to receive Therapeutic Treatment for Neurological Re-Education, Gait Training, Group Therapy and Therapeutic Activities 2 times a week for 4 weeks (ending on 2/23/24). R1 is also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to designate a qualified director of food and nutrition services. This failure has the potential to affect 38 out of 39 residents residing in the facility. Findings include: On 8/8/23 at 9:41 am, V3, Director of Food and Nutrition Services (Dietary Manager) was actively managing and directing the services of the facility's kitchen and staff preparing residents food. On 8/8/23 at 9:50 am, V3 exhibited a Certified Food Protection Manager certificate, valid through 8/12/24. V3 stated this certificate was achieved from an 8 hour course in food sanitation. V3 stated she is a high school graduate, does not have a Certified Dietary Manager certificate, nor a Certified Food Protection Professional certificate. V3 stated she is not a Registered Dietician. V3 also stated she did not meet any of the state requirements for a Dietetic Service Supervisor by stating she is [AGE] years old so has had no courses prior to 1990 and does not have any military…

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 store food and food service utensils in a manner to prevent cross contamination of residents food. This failure has the potential to affect 38 of 39 residents residing in the facility. Findings include: On 8/7/23 at 9:15 am, there was a 10 pound package of ground beef thawing in the reach-in refrigerator. This thawing ground beef was stored above a package of hard boiled eggs. On 8/8/23 at 9:45 am, V3, Dietary Manager, stated, That meat shouldn't have been above the eggs. On 8/8/23 at 9:50 am, there was a bulk container of flour in the facility's dry food storage room. Inside this bulk container was a foam cup, approximately 12 ounces, laying in direct contact with the flour. On 8/8/23 at 9:50 am, V3 stated, That cup should is not supposed to be left inside the container. The facility's policy Storage dated 10/2020 documents, Do not leave any serving utensils or tools in food containers. The facility's Resident Census and Conditions of Residents dated 8/7/23 documents 39 residents reside in the facility, all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide alternate meals to residents that did not eat what was served/or requested a substitute menu item. This failure affected five R9, R11, R17, R32, and R89 reviewed during resident group on the sample list of 20. Findings include: On 08/08/23 at 1:30 PM during a group meeting, residents stated the following: R9, stated the facility does not offer a substitution menu. R11 stated there are no substitute food items every available. R11 also stated R11 has asked several times. R17, stated there are no alternate menu items available during meals. R32 stated there are no substitutes offered for meals. R32 stated R32 sees many residents (unidentified) that can't speak for themselves, that don't eat what is served. Staff (unidentified) just remove the residents plate and do not offer anything else. R89 stated there are no substitutes for meals. Everybody gets whatever the facility wants to serve. R89 also stated R89 has asked staff (unidentified) and 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 interview and record review the facility failed to notify resident's family and physician of changes in condition for two (R25, R31) of 16 residents reviewed for change in condition in the sample list of 20. Findings include: The facility's Notification for Change in Resident Condition or Status dated 7/1/23 documents the nurse will notify the resident's representative/family and physician when there has been a change in the resident's physical/emotional/mental condition, a need to alter medical treatment, symptoms of infection, abnormal lab results, and weight loss of 5% in 30 days and 7.5% in 90 days. 1.) R25's Minimum Data Set, dated [DATE] documents R25 has severe cognitive impairment. R25's May 2023 POS documents an order dated 5/25/23 for a urinalysis with culture and sensitivity and an order dated 5/30/23 for Nitrofurantoin (antibiotic) 100 milligrams (mg) by mouth every 12 hours for 5 days. R25's Urine Culture with reported date of 5/30/23 documents R25's urine contained Proteus Mirabilis…

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, record review and interview, the facility failed to accurately encode three falls, on three different minimum data set assessments for a resident. The facility also failed to make corrections on the minimum data sets regarding residents falls, as directed by the facility policy. This failure affects one resident (R16) out of four residents reviewed for accident hazard/falls on the sample list of 20. Findings include: On 08/07/23 at 10:30 am, R16 was seated in a recliner next to her bed. R16 had deep purple, full facial bruising, below and above both eyes, chin, right side of her nose and her left cheek from a fall on 8/3/23. R16 stated R16 has had four falls from bed, which resulted in fractured left collarbone, and stitches in her head from those falls. 1. On 8/7/23 at 10:40 am V1, Administrator provided an Illinois Department of Public Health (IDPH) reportable fall on 2/5/23. This report documents R16 sustained a Left Clavicle fracture (major injury) from attempting to get out of bed. 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 interview and record review the facility failed to update comprehensive care plans for three residents (R2, R26, R31) of 12 residents reviewed for care plans in a sample list of 20. The facility failed to update care plans in four care areas (accidents, nutrition, anticoagulant, urinary catheter). Findings include: 1.) R2's Final report of incident dated 4/29/23 documents (R2) is independent with ambulation was found on the floor in her bedroom and sent to the emergency room for evaluation and treatment. (The facility was) notifies today of closed compression fracture of L3 and L5 Lumbar Vertebrae. R2's Care Plan includes an entry dated 6/8/22 documenting Falls: Risk factors Include: Hip Replacement, Hypertension, Chronic Obstructive Pulmonary Disease, Psychotropic Medication Use. The only updated intervention for falls since 6/8/22 is dated 4/14/23 and document Nonskid Strips in front of the toilet. The facility's policy Fall Prevention revised 11/10/18 states Immediately after any resident fall 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 assistance with shaving/grooming for two (R19, R25) of three residents reviewed for Activities of Daily Living (ADLs) in the sample list of 20. Findings include: 1.) On 8/07/23 at 9:30 AM R19 was sitting in a wheelchair in R19's room. R19 had long, dark, facial hair to R19's upper lip, chin, and cheeks. At 12:11 PM R19 was sitting in the dining room and had long, dark, facial hair. On 8/8/23 at 9:48 AM R19 was sitting in R19's room and had long dark facial hair to R19's upper lip, chin, and cheek. R19 made a shaving motion to R19's face and nodded yes when asked if R19 preferred to be shaved. At 3:34 PM R19 still had long, dark facial hair. R19's August 2023 Physician's Order Summary documents R19's has diagnoses of Self Care - Total Deficit, and history of intercranial injury and traumatic birth injury. R19's Minimum Data Set (MDS) dated [DATE] documents R19 requires extensive assistance of one staff for personal hygiene. 2.) 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 clean a wound during a wound treatment and label a dressing with a date for one resident (R31) reviewed for wounds in the sample list of 20. Findings include: R31's Physician Progress Notes dated 8/7/23 and recorded by V21 Podiatrist, documents R31's full thickness burn wound of the lower leg daily treatment order as collagen moistened with saline, cut to fit the wound, apply petroleum jelly dressing, cover with dry gauze, wrap with rolled gauze, and apply an elastic dressing to secure. This note documents to cleanse the wound with saline and the wound measured 10.5 centimeters (cm) by 2 cm by 0.1 cm. On 8/9/23 at 10:39 AM V22 Licensed Practical Nurse administered R31's wound treatment. V22 removed the undated dressing from R31's right outer calf wound. The wound was linear and had red/pink tissue. V22 did not cleanse the wound prior to applying the wound treatment of saline moistened collagen, petroleum jelly dressing, gauze dressing, and rolled gauze. V22 labeled the dressing with a date. At 11:02 AM V22…

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 label a pressure ulcer dressing with a date, implement pressure relieving interventions, and implement a treatment order for one resident (R31) reviewed for pressure ulcers in the sample list of 20. Findings include: R31's Minimum Data Set, dated [DATE] documents R31 has severe cognitive impairment, 4 unstageable pressure ulcers present on admission, requires extensive assistance of one staff for bed mobility, and requires dependence on two staff for transfers. R31's Care Plan initiated on 6/25/23 documents R31 is at high risk for pressure ulcers and includes an intervention to notify the physician of any open or bruised areas. There is an intervention dated 2/24/23 to refer to the Physician's Order Summary for current wound treatment orders and interventions dated 3/6/23 to check right heel every 2 hours, air mattress, and heel protector boots. There is no documentation of any new pressure relieving interventions for R31's heels after…

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 a safe environment for residents at risk for falls, failed to care plan a targeted intervention post fall, failed to investigate an improper transfer of a resident and implement interventions to prevent improper transfers. This failure affects three of four residents (R4, R16, R239) reviewed for accidents/falls on the sample list of 20. Findings include: 1. R4's Physician Order Sheet (POS) dated 8/1/23- 8/31/23 documents the following diagnoses Chronic Back Pain, Kyphosis, Spinal Stenosis, History of Stroke, and Restless Leg Syndrome. R4's Minimum Data Set (MDS) dated [DATE] documents the following: R4's Brief Interview of Mental Status score of nine, out of possible 15, indicating severe cognitive impairment. The same MDS documents R4 requires extensive physical staff assist of one person with bed mobility, is totally dependent of two staff for transfers, and has bilateral lower extremity impairment in range of motions. R4 Fall…

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 timely report urine culture results to the physician and timely implement antibiotic orders for one resident (R26) reviewed for Urinary Tract Infections (UTIs) in the sample list of 20. Findings include: On 08/07/23 at 2:48 PM V8 (R26's Family) stated R26 gets frequent UTIs and one time R26's urine sample was collected on a Friday and the results were not available until Thursday. V8 stated that day an unidentified nurse told V8 that a prescription was ordered, and the medication would be delivered that night. R26's Minimum Data Set, dated [DATE] documents R26 has severe cognitive impairment. R26's Care Plan dated 3/15/23 documents R26 has bladder incontinence and includes interventions to notify the physician of symptoms of UTIs. R26's Urine Culture collected on 5/24/23 and reported on 5/27/23 documents Proteus Mirabilis (bacteria) greater than 100,000 Colony Forming Units (CFU). This lab result includes a handwritten order dated 5/29/23 for Levaquin…

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 nutritional supplements as ordered, failed to document nutritional supplement intakes, and failed to timely identify significant weight loss and report significant weight loss to the physician and dietitian for two (R31, R2) residents reviewed for nutrition in the sample list of 20. This failure resulted in R31 experiencing a significant weight loss of 13.53% in 90 days. Findings include: The facility's Resident Weight Monitoring policy dated as revised March 2019 documents the following: Monthly weights are to be obtained by the 5th of each month. The Dietary Manager and Director of Nursing are responsible for reviewing the monthly weights by the 8th of each month. The Food Service Manager and interdisciplinary team review weights, nutritional status, and make recommendations for nutritional interventions. The physician and dietitian will be notified of significant weight loss of 5% or more in one month, 7.5 % or more in three…

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

Based on interview and record review the facility failed to assess at least quarterly, document nonpharmacological interventions, and obtain informed consent for one resident (R2) who receives psychotropic medication of five residents reviewed for psychotropic medications in a sample list of 20 residents. Findings Include: R2's Physician's Order Sheet (POS) for August 1st, 2023, through August 31st, 2023, includes the following current physician's orders for psychotropic medication: Citalopram (Antidepressant) 40 milligrams daily. 2. Risperdal (Antipsychotic) 2 milligrams twice daily. 3. Geodon (antipsychotic) 60 milligrams twice daily. 4. Trazadone (antidepressant) 50 milligrams twice daily. and 5. Melatonin (sleep aid) 3 milligrams at bedtime daily. The most recent assessment for R2's citalopram, Risperdal, and Geodon are dated 4/7/23. There are no documented assessments for R2's Trazadone or Melatonin. The dosage on R2's consent for Trazadone is documented as 25 milligrams. The current dosage being administered is 50 milligrams twice daily. There is no documentation to support…

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 designate a Registered Nurse to serve as the Director of Nursing. This failure has the potential to affect all 43 residents residing in the facility. Findings include: On 8/9/22 at 9:30 am, V1, Administrator, stated, We do not have a Director of Nursing at this time. We do not have anyone acting as Director of Nursing. The facility's Quality Assurance Committee sign in sheets dated for 1/19/22, 4/20/22, and 7/20/22, have a blank line where a D.O.N. (Director of Nursing) should have signed. The Facility assessment dated [DATE] documents the facility requires the services of a Registered Nurse as full time Director of Nursing to provide competent support and care for the resident population, documented as 40% of the residents require skilled rehabilitation, 11% special high care, 8% clinically complex, 10% IV medications, and 75% isolation or quarantine for active infectious disease. On 8/10/22 at 4:15 pm, V4, MDS Coordinator/ Licensed Practical Nurse,…

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 the ice machine in a sanitary manner and failed to store food products with documented dates of opening packages and dates to discard opened food items. This failure has the potential to affect nearly all 43 residents who reside in the facility. Findings include: 1) On 8/9/22 at 10:27 am, the facility's ice machine, located in the facility kitchen, had thick encrusted mineral deposits streaking on multiple surfaces, and there was a pink slime substance on the plastic ice discharge chute on the interior of the ice machine (direct contact with the ice). V15, Dietary Manager, obtained a clean hand towel and wiped pink substance congealed onto the hand towel in a 1 inch area of thick red gelatinous residue. On 8/9/22 at 10:27 am, V15, Dietary Manager, stated, What is that. I suppose it doesn't matter what it is, it's dirty. On 8/11/22 at 1:58 pm, V15 stated, The ice machine is the only ice machine in the building. Every resident gets ice from that machine with the exception of 1 resident who is nothing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to include a minimum required member, the Director of Nursing, in their Quality Assessment and Assurance Committee for the past three quarterly meetings. This failure has the potential to affect all 43 residents residing in the facility. Findings include: On 8/9/22 at 9:30 am, V1, Administrator, stated, We do not have a Director of Nursing at this time. We do not have anyone acting as Director of Nursing. The facility's Quality Assurance Committee sign in sheets dated for 1/19/22, 4/20/22, and 7/20/22, have a blank line where a D.O.N. (Director of Nursing) should have signed as attending the meeting. The facility assessment dated [DATE] documents the facility requires the services of a Registered Nurse as full time Director of Nursing. The facility Resident Census and Conditions of Residents dated 8/9/22 documents 43 residents reside in the facility.

Based on record review and interview, the facility failed to complete quarterly assessments not less frequently than once every three months. This failure affects seven residents (R1, R2, R3, R4, R6, R8, and R12) out of nine reviewed for assessments on the sample list of 29. Findings include: 1) R1's most recent quarterly Minimum Data Set (MDS) documents this MDS was transmitted as completed on 8/5/22. R1's previous quarterly MDS was dated 3/10/22. On 8/9/22 at 3:51 pm, V4, MDS Coordinator, stated and confirmed, I transmitted (R1's) most recent quarterly MDS on 8/5/22 and (R1's) previous MDS was dated 3/10/22. 2) R2's most recent quarterly Minimum Data Set documents this MDS was transmitted as completed on 8/5/22. R2's previous quarterly MDS was dated 3/15/22. On 8/9/22 at 3:51 pm, V4, MDS Coordinator, stated and confirmed, I transmitted (R2's) most recent quarterly MDS on 8/5/22 and (R2's) previous quarterly MDS was dated 3/15/22. 3) R3's most recent quarterly MDS was dated as completed on 8/6/22 but had not yet been transmitted. R3's previous quarterly MDS was dated 3/16/22. 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 record review and interview, the facility failed to complete required comprehensive assessments within 14 days after admission, and annually. This failure affects two residents (R5 and R135) out of nine reviewed for assessments on the sample list of 29. Findings include: 1) R5's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] documents this MDS was an annual assessment. There was not a subsequent annual MDS in R5's medical record as of 8/9/22. On 8/10/22 at 3:51 pm, V4, Minimum Data Set Coordinator, stated, I am currently working on (R5's) annual comprehensive MDS which was due in June (2022). (R5's) last annual was done on 6/14/21. 2) The facility's Form 802 Matrix dated 8/9/22 documents R135 was admitted to the facility 7/7/22. R135's Profile Sheet confirms R135's admission date of 7/7/22, as does R135's Nursing admission Sheet. R135 did not have a completed comprehensive initial MDS in the medical record as of 8/10/22. On 8/10/22 at 2:50 pm, V4, Minimum Data Set Coordinator,…

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

Based on record review and interview, the facility failed to develop and implement a Comprehensive Plan of Care for R135. R135 is one of one resident reviewed as a new admission on the sample list of 29. Findings include: R135's Profile Sheet documents a facility admit date of 7/7/22. R135's Physician Order Sheet (POS) dated August 2022 includes the following medical diagnoses: Acute Cerebral Vascular Accident, Hypertension, Atrial Fibrillation, Anxiety, and Chronic Kidney Disease (Stage III). R135's Baseline Care Plan, dated 7/7/22 was located in the Medical Record, however, there was no Comprehensive Care Plan in the Medical Record for staff guidance in the ongoing care of R135. On 8/10/22 at 3:20 pm, V4, Care Plan Coordinator, confirmed R135's Comprehensive Plan of Care had not been completed, along with R135's Resident Assessment Instrument (RAI). V4 stated I am behind on RAI's and Care Plans and (R135) is one of them that I have not got to yet. V4 confirmed R135's Comprehensive Care Plan was due no later than 7/28/22. The facility policy titled Comprehensive Care Planning 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 observation, record review, and interview, the facility failed to implement fall prevention interventions according to resident's care plans. This failure affects two residents (R1 and R11) out of five reviewed for falls on the sample list of 29. Findings include: 1) On 8/9/22 at 1:19 pm, R11 was seated in a wheelchair in the facility dining room. R11 did not have a personal alarm on the wheelchair. On 8/10/22 at 11:57 am, R11 was seated in the facility dining room in a wheelchair. There was not a personal alarm in the wheelchair for R11. R11's Care Plan for fall prevention documents R11 slid out of the wheelchair on 7/3/22 and a post fall intervention was documented for a personal alarm for R11 while R11 is in the wheelchair, dated as initiated 7/3/22. R11's Fall Risk assessment dated [DATE] documents R11 received 22 points with a score of 10 or more being rated as high risk for falls. On 8/10/22 at 12:38 pm, V4, Minimum Data Set/ Care Plan Coordinator, stated, The alarm is a current intervention for…

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

Based on observation, record review, and interview, the facility failed to provide nutrition, according to Dietician recommendations and physician orders, through a gastrostomy tube for a resident experiencing weight loss. This failure affects one resident (R19) out of four reviewed for nutrition on the sample list of 29. Findings include: On 8/9/22 at 10:25 am, R19 was in bed with a gastrostomy tube feeding pump delivering Fibersource HN 1.2 (tube feeding product) at 70 cubic centimeters (cc's) per hour to R19 through R19's gastrostomy tube. At 2:47 pm, R19 remained in bed with the gastrostomy tube feeding pump delivering Fibersource HN 1.2 to R19 at the same 70 cc's per hour. R19's Dietary Services Communication dated 7/21/22 documents R19 had lost 3 pounds in the past month, and 7 pounds in the last 3 months. This same Dietary Services Communication documents R19's gastrostomy tube feeding rate on 7/21/22 was 70 cc's per hour for 20 hours per day and documented a recommendation from the Registered Dietician (V5) to increase R19's tube feeding to 75 cc's per hour for 20 hours per…

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 complete Quarterly Psychotropic Medication Assessments and failed to complete an Abnormal Involuntary Movements Scale (AIMS). This failure effected one of five residents (R10) reviewed for Psychotropic Medications on the sample list of 29. Findings include: R10's Physician Order Sheet dated August 2022 documents R10 is diagnosed with Dementia, Major Depression, and Schizoaffective Disorder Mixed Type. R10 is prescribed Citalopram (Antidepressant) 40 milligrams once per day, Risperidone (Antipsychotic) 2 milligrams two times daily, and Geodon (Antipsychotic) 40 milligrams with breakfast and 60 milligrams with dinner. R10's Citalopram, Risperidone, and Geodon Psychotropic Medication Quarterly Evaluations dated 6/13/22 were the only quarterly evaluations the facility completed within the last year. R10's AIMS (Abnormal Involuntary Movement Scale) dated 6/8/22 and 7/18/22 were the only AIMS completed for R10's Antipsychotic medications Risperidone or Geodon within the last year. The facility's Psychotropic Medication Policy…

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.