Elevate Care North Branch

Based on observation, interview and record review, the facility failed to ensure that dining service staff are wearing hair restraints (e.g. hairnet, hat and/or beard restraint) to prevent hair from contacting exposed food. This deficiency has the potential to affect 121 residents who consumes food from the kitchen. Finding includes: On 4/16/2025 at 11:30 AM, during subsequent visit to the kitchen to monitor food temperature, V25 (Dietary Aide) was observed in the kitchen without wearing a hair net. V25 said that he should have cover his hair with a hair net. On 4/16/2025 at 11:32 AM, V8 (Dietary Manager) said that V25 should have a hair net on. On 4/17/2025 at 1:32 PM, V1 (Administrator) said that he expects the dining service staff to wear the hair restraints. Facility Policy: Guideline & Procedure Manual Hair Restraints Guideline: The restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas, or when serving food. Procedure: 1. Staff shall wear hair restraints in all food production, dishwashing, and serving areas. 2. Hair restraints,…

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 use appropriate infection control practices during resident care on contact isolation precaution. The facility also failed to educate visitor on donning appropriate PPE (Personal Protective Equipment) when entering resident on contact isolation. This deficiency affects one (R47) of three residents in the sample of 28 reviewed for infection control. Findings include: On 4/15/25 at 12:18PM, R47's room was set up for contact isolation precaution. R47 is alert and pleasantly confused. Observed up in wheelchair with pillow place on her lap creating space between lunch tray placed on bedside tray table in front of her. She is eating by herself, with food all over her chest and lap. She is using spoon and her hands to eat. The pillow is soiled with food. She has her cellphone connected to outlet which is wet/soiled with food. Observed right hand fingers are reddened and swollen compared to left hand fingers. Observed long and dirty bilateral hand nails, with black matter inside the nails. Observed visible rashes 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 follow their incontinence care policy by not checking for incontinence at least every two hours. This affected one of three residents (R1) reviewed for incontinence care. This failure resulted in R1 being soaked in urine for and not checked for incontinence for at least 4 hours. Findings Include: R1's minimal data set section C (cognitive pattern) dated 2/21/25 documents a score of fourteen which indicated cognitively intact. Section GG (functional abilities) document: toilet hygiene dependent helper does all the work. Resident does none of the effort to complete the activity. Section H documents: urinary continence: always incontinent. On 3/1/25 at 11:23am, V4 (CNA) said she started her shift at 7am. V4 said she checked on R1 between 7:00am -8:30am. R1 did not ask to be changed at that time. V4 said R1 asked for some water and a blanket which V4 provided. V4 said this is the first time she was providing incontinence care to R1. R1 had a strong smell of urine. R1 was observed with a saturated adult brief, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the confidentiality of a resident's financial records. This failure applied to one (R1) of three residents reviewed for privacy and confidentiality. Findings include: R1 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: Parkinson's disease, CHF, ESRD, COPD, dementia, delirium, and depression. R1's face sheet shows R1 is his own decision maker, however V7 (Family Member) is R1'S substitute decision maker. On 2/10/2025 at 12:45PM, V3 (Business Office Manager) said, I am responsible to handle the residents financial accounts. I receive and submit payments for them. Resident's financial information is confidential, and I never send e-mails containing any of this information. At 1:05PM, V10 (VP of Accounts Receivable) said we had a situation where V7 (family member) made a payment to the facility, but we did not…

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 plan of care to prevent further fall and failed to keep the resident's immediate surroundings free of accidental hazards. This failure affects 1 (R1) of 4 residents reviewed for falls. Findings include: R1 is a [AGE] year old with diagnoses including but not limited to fracture of medial condyle of right tibia, fracture of seventh cervical vertebra, hypertensive heart disease, congestive heart failure, chronic obstructive pulmonary disease, spinal stenosis and repeat falls. Facility records showed post-fall assessments indicating R1's numerous falls on 7/9/23, 8/14/23, 10/21/23, 12/21/23, 3/4/24, 6/28/24, and with the most recent 7/6/24. On 8/3/24 at approximately 10:10 AM, surveyor entered R1's room which appeared dark and with no lighting turned on. R1 was lying awake in the first bed and a call light cord appeared above R1's bed away from her reach. There was one fall mat on the right side of the bed, however on the left…

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 interviews and record review, the facility failed to notify and inform a resident's primary care physician (PCP) of the onset of a resident's elevated heart rate, interventions of a nurse practitioner and respiratory therapist not directly under the PCP, and continued changes of condition, including but not limited to abnormal labs for a resident within a timely manner. This applies to 1 resident ([R1]) in the sample. Findings include: According to the Facesheet, [R1] was a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Acute and Chronic Respiratory Failure with Hypoxia; Tracheostomy; Spastic Quadriplegic Cerebral Palsy; Seizures; Encounter for Attention to Gastrostomy; Myoneural Disorder; and Unspecified Intellectual Disabilities. [R1]'s care plan dated 06/13/2024 reads in part, [R1] has a Tracheostomy s/p acute and chronic respiratory failure with hypoxia. Interventions: Monitor for signs/symptoms of respiratory distress (restlessness, agitation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that low air loss mattresses were set at appropriate weight settings for five of five residents (R70, R80, R105, R124, R129) reviewed for low air loss mattresses in the sample of 27. Findings include: 1. On 4.20.2024 1:05 PM, R124 was observed resting in bed on a low air low mattress; weight was set for 230 pounds. V2 (Director of Nursing-DON) said, R124 doesn't look like he weighs 230 pounds. R124's face sheet documents a [AGE] year-old admitted to the facility on 12.4.2023 with diagnoses including but not limited to Sepsis, Elevated white blood count, Encounter for attention to tracheostomy, Dependence on respirator (Ventilator) status, and Pressure ulcer of unspecified part of back, stage 4. R124's MDS (Minimum Data Set of 3.19.2024) does not document R124's cognitive status or pressure ulcer risk. R124's current weight (4.3.2024) is 110.4 pounds. R124's Order summary report documents Low air loss mattress in use. Check 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, interview, and record review, the facility failed to follow infection control practices and discard soiled personal protective equipment/PPE appropriately for one resident (R246). This failure has the potential to affect 16 residents residing on the same wing in a total sample of 27. Findings include: On 04/20/2024 at 11:05AM, V10 (Agency Licensed Practical Nurse/LPN) informed surveyor that he is the nurse assigned to care for all residents residing on the 1-O unit of the facility. V10 informed surveyor R246 is on contact isolation due to R246 having a diagnosis of influenza. On 04/20/2024 at 11:48AM, surveyor observed V10 exiting R246's room wearing a gown and gloves. V10 began ambulating down the hall with the potentially infectious gown and gloves on. V10 then walked back into R246's room and doffs the gown and gloves in the hallway outside of R246's room. V10 placed the gown and gloves on top of R246's isolation cart located outside of R246's room. V10 then picked the gown and gloves up off the isolation cart and transported them to the nurse's station 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 feed a resident in a dignified manner, for one of 12 residents (R44) reviewed for dining task and failed to provide feeding assistance to cognitively impaired resident with history of weight loss for one of three residents (R29) reviewed for feeding assistance in the sample of 27. Findings include: 1. R44's face sheet documents R44 is a [AGE] year-old admitted to the facility on 5.16.2023 with diagnoses including but not limited to: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 kidney disease, Dependence on renal dialysis, Type 2 diabetes mellitus, and unspecified atrioventricular block. R44's MDS (Minimum Data Set of 4.8.2024) documents R44 is cognitively intact. On 4.20.2024 at 12:09 PM, V7 (Certified Nursing Assistant) was observed standing at R44's bedside while feeding resident. On 4.20.2024 at 12:16 PM, V7 said, I should be sitting when I feed residents. Feeding and Assisting Residents to Eat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were self-administering medications had a self-medication administration evaluation and a care plan (R55, R105) and failed to have a physician's order for self- administration of medications (R105) for three of three residents reviewed for self-administration of medications in the sample of 27. Findings include: 1. On 4.20.2024 at 12:28 PM, two Fluticasone Propionate Nasal sprays were observed at R55's bedside. V55 said he self-administers the nasal spray. R55's face sheet documents R55 is a [AGE] year-old admitted the facility on 3.31.2024 with diagnoses including but not limited to: Hypertensive heart disease with heart failure, Acute and chronic respiratory failure with hypercapnia, Dependence on supplemental oxygen, Unspecified asthma, and Morbid (severe) obesity due to excess calories. R55's MDS (Minimum Data Set of 4.7.2024) documents R55 is cognitively intact. R55's Self-medication administration evaluation 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 medication administration policy by 1) not locking the medication cart when out of sight of the medication nurse, 2) by leaving medications on top of the medication cart for 2 residents (R90 and R246) while the medication cart was in the hallway and the medication nurse was out of sight of the medication cart, and 3) leaving medications unattended at a resident's bedside (R55). Findings Include: R90's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Dysphagia following Cerebral infarction, Epilepsy, unspecified, intractable, without Status Epilepticus, Type 2 Diabetes Mellitus with Hyperglycemia, Morbid (Severe) Obesity due to excess Calories, Chronic Kidney Disease, Stage 3 Unspecified, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Chronic Pain Syndrome, Gastro-Esophageal Reflux Disease without Esophagitis, Major Depressive Disorder, Single…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately inform resident representative(s) when there was an accident/incident involving resident which resulted in injury for 1 (R1) of 3 residents reviewed for notification of changes. Findings include: R1 is an [AGE] year old with diagnosis in part with chronic kidney disease with heart failure, atrial fibrillation, congestive heart disease and mild cognitive impairment. The facility's internal investigation, along with the surveyor's investigation of R1's fall showed the following: On 12/24/2023 00:42 (12:42 AM) V5 (LPN) wrote in part: Nurses Note. 11:10 PM, CNA doing rounds found the patient on the floor by the side of the bed. Patient found lying on the left side of the body with the right leg straight and left leg slightly flexed. V5's signed statement on 12/26/23 obtained by V2 (director of nursing), reads in part, I (V5) came to my scheduled shift 12/23/23. Once I got into the unit, agency nurse was rushing to go home. Both of us did 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.

On 12/1/2023 at 12:38p, V2 (Director of Nursing/DON) stated the for 11pm-7am shift, on the first floor there is one nurse for 1-A and one nurse for 1-0 units with 2-3 CNAs for 1- A and 2 CNAs for 1-0. For 2nd floor there is one nurse for 2-A and one nurse for 2-0. We staff with 2-3 CNAs for 2-A and 2 CNAs for 2.0. If there is a call in, we will staff with our own staff or agency. If we cannot find anyone either one of the nurse managers will come in or myself (V2) will come in. On 12/1/2023 at 1:04pm, V2 (Director of Nursing/DON) stated, We had a last-minute nurse that was a no call no show (NCNS) and we could not find anyone else. We had 3 CNAs on 2-A, no nurse and they were instructed to get a nurse if any resident asked for PRN meds. When asked if residents got their scheduled meds that were due between 11pm and 7am on 10/21/2023, V2 stated, If any scheduled meds were due, they did not receive their medications but I will have to check. V2 stated V2 is responsible for ensuring the facility is staffed with nurses. V2 stated, Usually, the managers will work but none of the managers…

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 nurse was on duty for the second-floor memory care unit A to administer significant medications. This failure affected 20 residents (R13 and R15-R32) out of 45 residents residing on the second-floor memory care unit. Findings include, On 12/2/23 at 11:08 am V2 (Director of Nursing) said he reviewed the medication administration records and he saw that on 10/21/23 the 6 am medications were not given to the residents on unit 2A unit. V2 stated, When the oncoming nurse came in, she just gave the 9 am medications that were due. V2 said, on 10/21/23 there was a nurse on the second floor for the 2-O unit, but no nurse on duty for unit 2-A (facility has 2 units on the second floor, 2-A and 2-O). On 12/2/23 at 11:37 pm, V12 (RN) said, one day in October she was the only nurse on the second floor for the 11 pm to 7 am shift. V12 said, she was assigned to the 2-O unit and there was no nurse for 2-A unit. V12 said, she was informed by V2 to give any requested PRN (as needed) medications and go to 2-A if a residents needed…

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 resident rooms and common areas were being maintained at comfortable air temperatures during an excessive heat warning. This failure affected 13 of 13 (R60, R14, R22, R23, R1, R55- R59, R31, R28, R29) reviewed for inadequate cooling. Findings include: On 8/24/23 at 12:18PM, tour with V3 (maintenance director) said, he monitors the thermostats daily to ensure they are at 70 -75 degrees Fahrenheit (F). V3 denied any concerns with air-conditioning prior to the tour. V3 said he checked the temperatures earlier that morning with no concerns. Surveyor team conducted tour of facility with V3 (maintenance director) to observe and record resident room temperatures. V3 had an infrared thermometer with no humidity reading on the device. On 8/24/23 at 12:50PM, R60's room temperature was observed at 83 degrees (F). R60's wall unit air conditioning was not working. R60 complained of his room being hot. R60 said his air conditioning unit has been…

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, this facility failed to ensure licensed nursing staff were able to demonstrate the knowledge and skills to monitor midline and PICC (peripherally inserted central catheter) intravenous sites for complications, including infection and blood clots, administer intravenous medications, and perform central line intravenous catheter dressing changes for six residents (R17, R26, R27, R30, R37, R39) out of six residents reviewed for care and management of midline and peripherally inserted central intravenous catheters. Findings include: On 8/1/23 at 1:50pm, V2 DON (director of nursing) stated an LPN (licensed practical nurse) can administer an intravenous (IV) antibiotic into a peripheral intravenous continuous infusion. V2 stated the nurses are expected to be monitoring peripheral, midline, and PICC (peripherally inserted central catheters) intravenous sites for swelling, leaking, not flushable, and no blood return. V2 stated if nurse observes any of these signs, the nurse is expected to stop the infusion and contact the physician 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 observations, interviews, and record reviews, this facility failed to ensure licensed nursing staff were able to demonstrate the knowledge and skills to monitor midline and PICC (peripherally inserted central catheter) intravenous sites for complications, including infection and blood clots, administer intravenous medications, and perform central line intravenous catheter dressing changes for six residents (R17, R26, R27, R30, R37, R39) out of six residents reviewed for care and management of midline and peripherally inserted central intravenous catheters in a sample of 48. Findings include: On 8/1/23 at 1:50pm, V2 DON (director of nursing) stated an LPN (licensed practical nurse) can administer an intravenous (IV) antibiotic into a peripheral intravenous continuous infusion. V2 stated the nurses are expected to be monitoring peripheral, midline, and PICC (peripherally inserted central catheters) intravenous sites for swelling, leaking, not flushable, and no blood return. V2 stated if nurse observes any of these signs, the nurse is expected to stop the infusion and contact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the Illinois Respiratory Act and job description qualifications and have a licensed respiratory therapist. Unqualified staff was observed performing respiratory care on three of three residents (R35, R37 and R47) reviewed for licensed respiratory therapist. Findings include: On 8/4/23 at 4:02am, V58 (respiratory therapist) was observed wearing an ID with his typed name and the word student underneath. V58 said, I passed my boards. I am not a student. This is my first night working. V58 provided suctioning for R47. V58 was the only respiratory therapist working unit 1A. At 5:00Am, V58 (RT) was observed providing tracheostomy suctioning for R37. At 5:30, V58 (RT) was observed performed suctioning R35. R35's respiratory administration record for August documents V58 (respiratory therapist) signed off on the following care: tracheostomy care, oral care, and suction tracheostomy. R37's respiratory administration record for August…

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 There are 2 Deficiency Practice Statements on this tag: Based on observations, interviews, and record reviews, the facility failed to provide staff training and perform daily AED battery checks to ensure the two AEDs were in good working condition. Findings include: On 7/27/23 at 2:45pm, this surveyor observed the AED device for the second-floor nursing units was flashing red. The pads were not connected to the device. On 7/27/23 at 2:45pm, this surveyor asked V49 LPN (licensed practical nurse) to demonstrate location of battery on the AED device. V49 was observed turning the AED and looking at device from all angles. V49 stated V49 is not sure where the battery is located and if there is a spare battery for this device. V49 turned on the AED device and the voice prompt stated replace battery now. V49 turned off the device and placed back on wall where it is stored. V49 did not change the battery or notify staff device needed a new battery. On 7/27/23 at 2:55pm, this surveyor observed the AED device 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.

Based on interviews and record reviews, the facility failed to notify a resident's representative/POA (power of attorney) with changes in skin condition and new treatment orders. This failure affected one resident (R41) out of three reviewed for notification of change in condition in a sample of 60. Findings include: On 8/25/23 at 11:55am, V21 (nurse supervisor) stated V84 (attending physician) asked her to check the results of the scabies test performed on R41. V21 stated she relayed results to V84 and R41's nurse. V21 stated V21 is unsure of which nurse she notified. V21 stated V21 asked the nurse to contact R41's family of negative results. V21 denied following up to ensure R41's family was notified. On 8/25/23 at 12:15pm, V4 (wound care nurse) stated V4 informed infectious disease physician on 8/17/23 R41's scabies test result was negative and V4 received an order for a dermatology consult. V4 denied informing R41's POA of the test result prior to 8/23/23. On 8/25/23 at 1:20pm, V2 DON (director of nursing) stated R41's MAR (medication administration record) notes R41's skin is…

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 the Abuse Prevention and Reporting policy by not immediately reporting an allegation of abuse to the regulatory agency. This affected one of three residents (R13) reviewed for abuse reporting. Findings include: On 7-25-23 at 1:06 PM, Surveyor informed V1 (Administrator) about allegation of visitor to resident (R13) mental abuse. On 7-26-23 at 12:16 PM, V1 (Administrator) said she did not report allegation of visitor to resident mental abuse yesterday (7-25-23) and said she will report allegation to state agency today (7-26-23). V1 said she did not send the reportable on 7-25-23 when surveyor made concern of allegation because she wanted to clarify. V1 asked for clarification at 12:16 PM on 7-26-23, however the surveyor has been at the facility since 8:45 AM on 7-26-23. V1 said she faxed the Initial Stated reportable on 7-26-23 at 1:54 PM as documented on the fax confirmation. Abuse Prevention and Reporting - Illinois (reviewed 10-24-22) documents: Any allegation of abuse or any incident that results in serious…

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 staff assisted activities of daily living to include incontinence checks and care at least every two hours, and bathing at least twice a week. This affected four of four residents (R27, R10, R35, and R41) all reviewed for activities of daily living. This failure resulted in R27 developing facility acquired moisture associated dermatitis. Findings include 1. R27 has the diagnosis of Anoxic Brain Damage and Ventilator dependence. Minimal data set section G (functional pattern) dated 6/6/23 document: R27 is total dependent with one-person physical assist with personal hygiene - how a resident washes/ drying face/hand and toileting. Wound assessment date 7/19/23 documents: R27 had a facility-acquired, moisture associated dermatitis (MASD), located on his peri-anal area identified on 06/28/2023 measuring 4.00 x 4.00 x 0.00 (L x W x D) with a surface area of 16.00 cm3. On 8/4/23 at 8:08am, V2 (DON) said, ADL care includes but not limited to incontinence care and daily hygiene. A resident's face should be free…

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 cardiopulmonary policy by not assessing the 6 criteria for signs of irreversible death prior to initiating CPR. This affected one of one resident (R16) reviewed for appropriateness of CPR (Cardiopulmonary Resuscitation). This failure resulted in R16 being found lifeless, unresponsive with rigor mortis, skin mottled, pooling of blood to the back side when 911 arrived with facility staff performing CPR. Findings Include: Nursing note documented on [DATE] at 6:23AM, reads in part: R16 was found unresponsive and with no pulse or respiration by the nurse at approximately 6:15AM. Code blue called. 911 called. R16 was still warm to the touch. CNA stated she last saw resident at around 4 am and R16 was able to open his eyes. R16 full code status. On [DATE] at 12:00 PM V16 (RN) stated V16 was assigned R16 on [DATE] night shift. V16 stated the last time he saw R16 was at around 2 am and CNA last saw R16 around 4 am. At approximate 6 in the morning,…

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, that facility failed to follow physician orders by not ensuring a stat abdominal x-ray for an acute change in condition of an abdominal bulge. This affected one of three residents (R6) reviewed for radiology orders. This failure resulted in a 2-day delay in a needed G-tube replacement. Findings Include: On 7/27/23 at 12:38pm, V30 (nurse) said, R6 had a stat order for an abdominal x-ray (KUB) that was not completed. Stat orders should be completed within two (2) hours and if not done, then the doctor must be notified. On 8/02/23 at 3:41pm, V48 (lab personnel) said, I don't see an order for R6's stat (KUB) on 4/6/23. Stats are a priority. R6 has an order for a KUB placed on 4/7/23. On 8/3/23 at 9:19am, V59 (nurse practitioner) said, I was not informed of R6 not having a stat KUB completed for more than 24 hours. I was not called. I expect to be called in any situation. I would have sent R6 out to the hospital. On 8/9/23 at 11:59AM, V2 (don) said stat x-ray should be performed within four (4) hours. If they are unable to provide service within time…

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 and interviews, the facility failed to ensure residents had a functioning call light system at the bedside. This failure affected one resident (R31) out of three residents reviewed for call lights. Findings include: On 8/4/23 at 4:30am, R35's bedside call light system was observed to have a plug in the wall and the call light cord removed from the plug. On 8/4/23 at 5:30am, V2 DON (director of nursing) stated every resident should have a call light cord kept within reach while in bed. V2 stated R35's call light system is nonfunctional and there is no way for call light to be activated to alert staff that R35 needs assistance. V2 stated R35's call light needs to be replaced immediately. On 8/16/23 at 11:30am, V2 DON stated this facility does not have a policy related essential equipment being maintained and operational.

Based on observation, interview and record review, the facility failed to post the daily nursing staffing. This failure has the potential to affect all 128 residents residing in the facility. Findings include: On 11/28/22 V1 (Administrator) present facility's census of 128 residents. On 11/28/2022 at 9:15 am, upon entrance to the facility, no daily staffing was observed posted in the facility. On 11/28/22 at 10:39 am, surveyor inquired about the posting of daily staffing with V12 (Receptionist). V12 stated, It (referring to the daily staff posting) should be posted here at the receptionist desk. I (V12) get it (referring to the daily staff posting) emailed from V3 (Staffing Coordinator) and place it here (pointing to an empty protector sheet stand). When V12 was asked when the last time the daily staffing was posted in the empty protector sheet stand at the receptionist desk, V12 stated, I (V12) don't know. V3 did not email it to me. On 11/29/22 at 9:40 am, V3 (Staffing Coordinator) was interviewed regarding the daily staff posting for the facility. V3 stated that V3 is responsible…

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 food in the walk-in freezer was dated; failed to ensure expired food was discarded on or before the expiration date; and failed to ensure kitchen employees wore hair restraints while preforming kitchen duties. These failures have the potential to affect 116 residents in the facility who are receiving an oral diet. The findings include: On 11\28\2022 at 9:42am in the main kitchen observed V42 (Dietary Aide) standing in the middle of the kitchen with no hair net on V42's head. On 11\28\2022 at 9:45am in the walk- in freezer no dates were observed on a white box of frozen pasta spätzle dumplings and a white box containing young turkey meat. On 11\28\2022 at 9:50am observed a round white container of cottage cheese labeled with an expiration date of 9\24\2022. On 11\30\2022 at 12:04pm V42 (Dietary Aide) stated, I don't know why I have to wear a hairnet. V42 stated someone taught me to wear the hairnet and that is what I do. On 11\30\2022 at 12:05pm V4 (Dietary Manager/Food Service Director) stated 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 observation, interview and record review the facility failed to ensure the outside dumpster lid was free of holes to prevent pests and rodents from entry into the garbage bin. This failure has the potential to affect all 128 residents residing in the facility. Findings include: The (11\28\2022) facility census was 128. On 11\30\2022 at 12:52pm, the outside large dumpster was observed with an open hole on the black lid top. Three gray squirrels were observed going into the and out of the open hole on the black lid top of the large dumpster. This surveyor pointed this out to V25 (Director of Maintenance). V25 stated, The hole in the garbage dumpster lid is not supposed to be like that because the squirrels and rats will be able to get into the garbage dumpster. The surveyor inquired about the importance of the dumpster lid being free of holes and damage. V25 stated, To make sure no animals get into the dumpster. We (the facility) don't want to attract animals that may go inside the building. The 12\01\2022 email correspondence with V1(Administrator) documented in part 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.

Based upon observation, interviews, and record review the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual (1:1) activities for four of four residents: (R1, R91, R32, and R2) from a sample of 58 residents, with the potential to affect the entire 2A unit. Findings during a survey conducted at the facility on 11/28/2022 include: On 11/28/2022 at 11:34 AM, R1 was observed in bed room alone in bed with a frown upon his face. When writer asked V8, Nurse Supervisor, if R1 gets out of bed, she replied, He doesn't get out of bed much. He doesn't like going to the activity room with his peers. R1 has a BIMS (Brief Interview for Mental Status) score of 3 which indicates cognitive impairment. R1 has the following diagnosis: Unspecified Dementia, Unspecified severity with other behavioral disturbances, Legal blindness, and Depression unspecified. Surveyor then visited the activity room at 11:40 AM and observed residents sitting quietly without activity in progress. Upon searching for an activity aide,…

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

Based on observation, interview and record review, the facility 1. failed to discard expired medications; 2. failed to discard medications of discharged and expired residents; 3. failed to maintain adequate temperature for 1 medication room refrigerator out of 2 refrigerators reviewed and; 4. failed to ensure 2 medication carts are locked out of 4 medication carts reviewed; The deficient practices affected R85, R94, R104, R116, R131 and R485 and has the potential to affect 48 residents who receive medications from 3 medications carts out of the 4 carts reviewed for medication storage and labeling. Findings include: On 11/28/22 at 10:58 AM with V16, Registered Nurse, refrigerator inside 1st floor medication room was inspected. V16 stated the thermometer is registering a temperature of 53 degrees Fahrenheit. V16 also stated that she is not sure what the temperature range should be. Inside the 1st floor medication room refrigerator, the following were observed with V16, Registered Nurse: R485 has 4 Kwik pens of Insulin Glargine 100 units/ml inside the medication room refrigerator. V16…

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 ensure the resident's call device has a call device string long enough to be within easy reach of a resident. This failure affected 1 (R7) resident reviewed for Call Device in a total sample of 58 residents. Findings include: On 11/28/2022 at 12:05pm, R7's call device string was about 2 -3inches from the switch, not within reach of R7. This surveyor pointed this out to V18 (Social Service Director). V18 checked R7's call device and stated, Call light string got disconnected, not within his (R7) reach. There is no way for (R7) to call for help. So, we are going to fix that. R7's (10/17/2022) Minimum Data Set documented, in part: Section C. Cognitive Patterns. C0500. BIMS Summary Score: 8. Indicating R7's mental status was moderately impaired. Section G. Functional Status. G0110 Activities of Daily Living (ADL) Assistance. I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfer on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts…

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 sanitary, homelike environment for 2 residents (R77 and R90) in the sample of 58 residents. Findings include: On 11/28/22 at 11:04 AM, V9 (Certified Nursing Assistant/CNA) was made aware of trash on R77 and R90's bedroom floor, including 3 disposable gloves, an empty wipe pouch and crumbs/debris. V9 stated, That's gloves on the floor and empty wipes. The surveyor pointed out the overflowing trash can with no liner and inquired who is responsible for ensuring that the trash is maintained. V9 replied, Usually I can grab whatever, but there were no trash bags in here. V9 stated that housekeeping is down the hall and hasn't made her way down to this room yet. At 11:08 AM, R90 walked into the room and picked up the gloves off the floor with his (R90) bare hands and placed the gloves on his (R90) finished breakfast tray. V9 instructed R90 to leave it and that she (V9) would take care of it, but R90 picked up the gloves anyway. On 11/28/22 at 11:20 AM, V6 (Housekeeping Director) stated that housekeeping…

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 upon observation, interview, and record review the facility failed to ensure that resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors while residing in the facility. This affected R1, one of four residents in a sample of 58 residents. Findings during survey conducted at the facility include: On 11/28/2022 at 11:30 AM R91 noted in bedroom yelling out. When surveyor asked what was wrong, R91 replied, Nothing. Two roommates were present in the room watching television. Surveyor asked nurse V8, Nurse Supervisor, if R91 yelled out often. V8 replied, This is normal for her. I just gave her some Tylenol. R1 was admitted to the facility on [DATE]. R1 has the following diagnosis: Alzheimer's disease with late onset, unspecified dementia- unspecified severity with other behavior disturbances, and other recurrent depressive disorders. The last Psychiatric Evaluation was completed on 9/13/2021. It was recommended per the evaluation that 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 have a five percent (5%) or lower medication error rate. There were five medication errors out of 30 medication opportunities, resulting in a 16.67% medication error rate and affected three (R35, R55, R99) residents observed for medication pass. Findings include: On 11/29/22 at 8:33 am, V22 (Registered Nurse, RN) was observed on the second floor at the 2A team 2 medication cart. Surveyor observed V22 prepare and count 4 pills total that were administered to R35. Upon surveyor reconciling R35's medications that were ordered for administration and medications that were observed as administered and documented by V22, the following medication error was identified: 1.) Omission error: Folic Acid 1 mg give 1 tablet by mouth once a day for anemia related to iron deficiency anemia secondary to blood loss (chronic). 2.) Omission error: MiraLax Powder 17 gm/scoop 1 scoop by mouth two times a day for bowel management mix in water/liquid. R35's…

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

Based on observations, interviews, and record reviews, the facility failed to ensure resident's personal refrigerator has a temperature monitoring log for R122 and failed to ensure there are available functioning thermometers inside the residents' personal refrigerator for R59 and R122 to prevent foodborne illness. These failures affected 2 (R59 and R122) residents in the total sample of 58residents. Findings include: On 11/28/2022 at 11:25 AM, there was a small refrigerator by R122's bedside. V15 (Certified Nursing Assistant) checked R122's refrigerator for inside thermometer, per this surveyor's request, and stated, I (V15) am not seeing it right now. It should be inside the fridge. (V6) does her (V6) checks. (V6) is the Housekeeping Manager. On 11/28/2022 at 11:26 AM, V15 checked for R122's refrigerator temperature monitoring log, per this surveyor's request. V15 looked on the top and on the sides of R122's refrigerator and stated, It (temperature log) is usually on the side of the refrigerator. I (V15) don't see it now. On 11/29/2022 at 2:50pm, surveyor inquired about resident'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.