Arc At Normal

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement and revise a comprehensive care plan to address falls for two (R1, R3) of three residents reviewed for falls in a sample list of four.Findings Include:Fall Policy dated 10/2024 documents the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The same policy documents the care plan addresses each fall, Interventions are changed with each fall, as appropriate.1.On 09/19/25, R1's record review of undated care plan documents an admission date of 08/15/25 with diagnosis Fracture of Left Calcaneus, Type 1 Diabetes Mellitus with Other Skin Ulcer, Fracture of Shaft of Right Tibia, Closed Fracture with Nonunion, and Muscle Wasting and Atrophy. The same care plan documents: R1 is at risk for falls related to the fracture to right shoulder Date Initiated:…

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 initiate resident centered interventions to prevent falls for one resident (R1) of three residents reviewed for falls in a sample list of four residents. This failure resulted in R1 falling from the wheelchair.Findings Include:Fall Policy dated 10/2024 documents that the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The same policy documents the Director of Nursing or Designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. The same policy also documents Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service. Nursing personnel will be informed of residents who are at risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility repeatedly failed to ensure residents' right to be free from physical abuse of R8 by R9, R5 by R4, R12 by R11, and R13 by R9. R5, R8, R12 and R13, are four of 20 residents reviewed for abuse on the sample list of 25. Findings include:1.) R8's Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview of Mental Status (BIMS) score of six, out of a possible 15, indicating severe cognitive impairment . R8's same MDS documents R8 has had no delusions or hallucinations, and no behaviors directed towards self or others.R9's MDS dated [DATE] documents the following: R9's BIMS score of three out of a possible 15, indicating severe cognitive impairment. R9's same MDS documents R9 has had no delusions or hallucinations, and no behaviors directed towards self or others.The Facility Reported Incident (FRI) of 7/5/25/2601647 documents: Resident to Resident Physical Assault. The same FRI report documents the following: On 7/5/25 at 8:20 AM, (V4, Certified Nursing…

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 accurately encode minimum data sets for antipsychotic medications and falls, and failed to complete the correct minimum data set for a discharged resident. These failures affect two residents (R6 and R1) out of thirteen reviewed for minimum data sets on a sample list of 25.Findings include: 1. R6's Physician Order Sheet dated [DATE] documents R6 has a physician order to receive the antipsychotic medication Quetiapine in a dose of 100 milligrams daily, an order initiated on [DATE], the day of R6's admission to the facility. R6's Medication Administration Record dated for [DATE] documents R6 received this antipsychotic medication as ordered. R6's admission Minimum Data Set, dated [DATE] section N0450 documents R6 did not receive antipsychotic medications since admission to the facility. This section, when coded as affirmative, serves as a prompt for further questions about required dosage reduction attempts On [DATE] at 3:40 PM, V16, Minimum Data Set…

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 repeatedly to maintain complete and accurate medical records for two of 14 residents (R2 and R14) reviewed for accuracy of medical records on the sample list of 25.Findings include: 1.) R2's Physician Order Sheet dated 9/1/25 documents the following diagnosis and medication order: Ativan (name brand), ( antianxiety- Lorazepam) Oral Tablet 0.5 MG (Milligrams), Give 0.5 mg by mouth (PO) every 8 (eight) hours as needed (prn) for anxiety/agitation related to Anxiety Disorder, Unspecified for 14 months (inaccurate duration, exceeds the 14 day limit for prn anti-anxiety medication). Start date 07/29/25, end date of 9/26/26 (two-thousand twenty-six). R2 ‘s Consent dated 7/29/25, is incomplete, as it does not document the duration of time for Lorazepam 0.5 mg by mouth (PO) every 8 (eight) hours as needed (prn) for anxiety. R2's (Private Company) Psychiatry Note dated 8/22/25 documents the following: Type of Visit: Follow-up Visit :Chief Complaint: Per staff, patient exhibits agitation, aggression, and behavioral changes. The same…

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 protect two residents' (R1, R10) from physical abuse for two of eight residents reviewed for physical abuse in a sample list if 15. Findings Include: Facility Abuse Prevention and Reporting policy effective 09/2024, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The same policy documents physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The policy documents as part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment,…

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 protect the resident's right to be free from physical abuse by a staff member for one (R1) of three residents reviewed for physical abuse from a total sample list of nine residents. Findings include: The facility Abuse Prevention and Reporting-Illinois Policy dated 5/2025 documents the facility affirms the right of our residents to be free from abuse. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent abuse by staff and mistreatment of residents. This will be done by identifying occurrences and patterns of potential mistreatment, immediately protecting residents involved in identified reports of possible abuse and implementing systems to promptly and aggressively investigate all reports and allegations of abuse and making the necessary changes to prevent future occurrences and filing accurate and timely investigative reports. Physical abuse is defined in this policy as the infliction…

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

Based on observation, interview and record review the facility failed to report an allegation of abuse to the State Agency in a timely manner for one (R1) of three residents reviewed for abuse from a total sample list of nine residents reviewed. Findings include: The facility Abuse Prevention and Reporting-Illinois Policy dated 5/2025 documents the facility affirms the right of our residents to be free from abuse. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent abuse by staff and mistreatment of residents. This will be done by identifying occurrences and patterns of potential mistreatment, immediately protecting residents involved in identified reports of possible abuse and implementing systems to promptly and aggressively investigate all reports and allegations of abuse and making the necessary changes to prevent future occurrences and filing accurate and timely investigative reports. Physical abuse is defined in this policy as the infliction of injury on a resident that occurs other than by accidental means including…

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

Based on observation, interview, and record review the facility failed to provide the necessary linen supplies for 97(R2, R3, R8-R103) of 103 residents reviewed for linen supplies from a total sample list of 103 residents reviewed. Findings include: The facility provided grievance dated 3/3/25 documents that resident council complained that whites have been taking too long to come back from the laundry. The response was documented that the delay was due to the elevator not functioning. The facility provided grievance dated 5/5/25 documents that resident council continued to complain that there were no wash cloths or towels for morning care. On 5/19/25 at 2:30PM the west linen room did not contain any washcloths or towels. On 5/19/25 at 2:35PM, the laundry room contained one dryer that appeared to have towels drying in it. V9 CNA (Certified Nurses Assistant) confirmed that no other washcloths or towels could be located in the laundry room. On 5/19/25 at 2:45PM the east linen room contained 6 towels and no washcloths or bed pads. On 5/19/25 at 2:20PM, V12 (CNA) stated that there are…

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 protect the resident's right to be free from physical abuse by another resident for one of three residents (R1) reviewed for abuse in the sample of three. Findings Include: The Facility Abuse Prevention and Reporting policy effective 09/2024, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The same policy documents physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The policy documents as part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect,…

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 employ the services of a qualified director of food and nutrition services. This failure has the potential to affect all 105 residents residing in the facility. Findings Include: On 02/18/25 at 08:35 am V7, Dietary Manager (DM) was actively supervising dietary staff during breakfast meal service. V7 stated he has worked at the facility, as the dietary manager, since November 2024. V7 DM stated he has not taken the required classes to qualify as the dietary manager. On 2/19/25 at 2:45 pm V14, Regional Dietary Manager confirmed V7 DM has not had the training to qualify as the dietary manager. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 2/18/25 documents 105 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and food-borne illness, by failing to maintain clean food contact areas, free of grease-like substances, rust, dangling strands of accumulated dust-like substance, loose caulking and chipped paint. These failures have the potential to affect all 105 residents residing in the facility. Findings Include: On 2/19/25 at 12:30 pm during the follow- up kitchen tour with V7, Dietary Manager (DM)there was an approximate eight-foot long metal shelf, above the three well sink. The metal shelf above the three well sink had copious amounts of rust and brown and black grease-like debris adhering to the underside surface. Directly below the underside, soiled metal shelf are approximately twenty hanging brackets. There are presumably clean kitchen serving utensils, spoons, tongs, whisk, all hanging in groups from each of these bracket. The three-well sink has loose chipped caulking dangling into the wash and sanitization wells of the sink. There are two electrical outlet boxes…

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 maintain comfortable room temperatures for seven of seven residents (R37, R48, R55, R71, R80, R104, R105) reviewed for comfortable homelike environment on the sample list of 36. Findings Include: Resident Council Meeting Minutes dated 12/2/24 document resident complaints concerning it being too cold in the building. Resident Council Meeting Minutes dated 1/6/25 document resident complaints concerning resident rooms were really cold. Resident Council Meeting Minutes dated 2/3/25 document requests for plastic to be put on windows due to cold temperatures. On 2/18/25 at 11:00 AM the 100 Hallway was much colder than the common areas or other main hallways and dining rooms. On 2/18/25 at 10:35 AM the 101-115 Hallway registered a temperature of 66.2 degrees Fahrenheit (F). On 2/18/25 at 10:37 AM the temperature outside of room [ROOM NUMBER] registered at 65.7 degrees F. 1. R37's Minimum Data Set, dated [DATE] documents R37 is cognitively intact.…

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, inteview, and record review the facility failed to implement side rails only after completing a side rail assessment and obtaining informed consent for three of three residents (R10, R79, R88) reviewed for side rails on the sample list of 36. Findings Include: The facility's Side Rail/Bed Rail policy dated October 2024 documents the purpose of the policy is to ensure the appropriate, safe and correct installation, use, and maintenance of bed rails. The facility shall ensure that prior to the installation of bed rails, the facility has attempted to use alternatives. After alternatives to bed rails have been attempted and determined that these alternatives do not meet the resident's needs, the facility shall assess the resident for the risks of entrapment and possible benefits of bed rails. After alternatives have been attempted and prior to installation, the facility shall obtain informed consent from the resident or if applicable, the resident representative for the use of bed rails. 1.…

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 properly secure R96's indwelling catheter tubing to R96's wheelchair. R96 is one of two residents reviewed for urinary catheters on the sample list of 36. Findings Include: On 2/18/25 at 12:15 PM, R96 indwelling catheter tubing was dragging on the floor underneath R96 high back wheelchair. On 2/19/25 at 10:32 AM, R96 indwelling catheter tubing was dragging on the floor underneath R96 high back wheelchair. On 02/19/25 at 10:38 AM, V25 (Certified Nursing Aide) confirmed R96's indwelling catheter tubing was hanging underneath R96's highback wheelchair and stated that it should not be dragging on the floor. The facility Catheter Care Policy dated 10/2024 documents the following: to establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor directly.

Based on interview, and record review, the facility failed to administer intravenous medications as ordered by the physician. This failure affects two residents (R1, R2) out of three reviewed for intravenous medication administration on a sample of six. Findings include: Medication Administration Policy dated Effective 10/2024 states under section II. ADMINISTRATION OF MEDICATIONS: Medications must be administered in accordance with a physician's order, e.g., the right resident, right medication, right dosage, right route, and right time. R1's medical record documents on 11/7/2024, R1 was admitted to the facility with a diagnosis of ACUTE OSTEOMYELITIS, LEFT ANKLE AND FOOT requiring the treatment of intravenous antibiotics. R1's medical record documents on 11/7/24 at 4:39 PM R1 received the following admission order for: Vancomycin HCl Intravenous Solution (Vancomycin HCl); Use 2250 mg intravenously every 24 hours for osteomyelitis until 11/27/2024 administered daily at 1:00 PM. November 2024 medication administration record (MAR) documents on 11/25/24 at 7:11 PM that V10 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to care plan and develop/implement behavior tracking and interventions to address and prevent behaviors of inappropriate touching/sexual abuse for R1. R1 and R2 are two of seven residents reviewed for abuse in the sample list of seven. Findings include: The facility's Final Abuse Investigation Report dated 6/21/24 documents the following: On 6/18/24 at approximately 10:00 AM V3 Licensed Practical Nurse (LPN) witnessed R1 and R2 sitting beside each other in the [NAME] living area. V3 witnessed R1's hand on R2's chest, V3 immediately separated R1 and R2, and R1 was taken to R1's room. R1 and R2 were interviewed and had no recollection of the incident. R1 was placed on one to one supervision and (Psychiatry Company) was consulted. R1's ongoing Diagnoses List includes Dementia with behavioral disturbance, restlessness, agitation, and Pseudobulbar Affect (inappropriate/involuntary laughter or crying). R1's Minimum Data Set (MDS) dated [DATE] documents a Brief…

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 residents were free from sexual abuse for two of five residents (R1, R2) reviewed for abuse on the sample list of five. Findings Include: On 4/29/24 at 8:25 am, V3 (R1's family) stated R2 was roaming the halls and entered R1's room, placed R2's hand on R1's chest and R1's hand on R2's groin, without saying anything. V3 stated R1 started screaming no, no. get out and R2 left the room. V3 explained that R1 was so horrified, R1 didn't say anything about it to anyone until the next day, then R1 reported it to V4 Medical Director. V4 reported it to the facility and at that time, they got the police involved. R1 didn't want to press charges or anything, R1 just wants to forget that it happened. R2's ongoing Diagnosis Listing documents R2 has Metabolic Encephalopathy, Parkinson's, Dementia, and Cognitive Communication Deficit. R1's Progress Notes dated 2/7/24 by V2 DON (Director of Nursing) documents V4 Medical Director came to V2 and reported that while seeing R1, R1 reported that R1 saw a resident (R2) that R1 went to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent cross contamination of a wound, turn and reposition every two hours, document the receipt of wound treatments, and measure and assess wounds upon identification of the wound for three of three residents (R1, R9, and R10) reviewed for pressure ulcers on the sample list of ten. Findings include: The facility Pressure Injury and Skin Condition Assessment Policy dated January 2018 documents a wound assessment will be initiated and documented in the resident's chart when a pressure and/or other ulcers are identified by a licensed nurse. A Wound Assessment for each identified open area will be completed and will include: site location, size, stage of pressure ulcer, odor, drainage, description, and date/initials of the individual performing the assessment. The Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. The facility's Pressure Ulcer Prevention…

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 comfortable temperatures in a dining room and resident bedroom. These failures affected six residents (R39, R74, R76, R88, R91, R26) of six reviewed for comfortable temperatures on the sample list of 48. 1. On 1/21/24 at 9:30AM, R39's room had a space heater in use. The space heater was sitting on the counter, oscillating and blowing toward R39. On 1/21/24 at 9:00AM, V5, R39's Family Member stated that R39's room was cold and he visits daily. On 1/21/24 at 9:31AM, V19, R39's Family Member stated that they brought in a space heater for R39 approximately a week ago because her room was so cold. On 1/24/24 at 2:00PM, V1 Administrator said that the temperatures in R39's room on both 1/10/2024 and 1/16/2024 were below the acceptable range of 71 to 81 degrees Fahrenheit. The facility provided a temperature log dated 1/10/24 which documents R39's room was at 7:00AM 64.7 degrees Fahrenheit, 8:00AM 64.7 degrees Fahrenheit, 9:00AM 64.9 degrees Fahrenheit, 10:00AM 64.9 degrees Fahrenheit, 11:00AM 65.2 degrees…

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 showers and personal cares for residents dependent on staff for hygiene for eight (R13, R29, R30, R42, R46, R47, R68 and R207) of eight residents reviewed for hygiene on the sample list of 48 residents. Findings include: 1. R29's undated diagnosis sheet documents the following diagnoses: Open Reduction Internal Fixation of Right Femur, Left Bundle Branch Block, Vascular Dementia, Epilepsy, Dysphagia, Mild Intellectual Disability, Abnormality of Gait and Lack of Coordination. R29's Clinical Review dated 1/7/24 documents that R29 requires moderate assistance with personal hygiene. R29's Care Plan dated 12/11/23 documents that R29 requires assistance with personal hygiene. On 1/23/24 at 12:00PM, R29 was sitting at the lunch table and a patch of white hair was observed on R29's chin. R29 then stated, I want them to shave my hair. R68's undated diagnosis sheet documents the following diagnoses: Cerebrovascular Incident, Dysphagia,…

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 accurately complete R93's comprehensive assessment. This failure affects one (R93) of three residents reviewed for accuracy of assessments on the sample list of 48. Findings include: R93's Minimum Data Set, dated [DATE], documents R93 received nutrition via a feeding tube. R93's Physician Orders documents R93 enteral feeds ended in July 2023. On 1/24/24 at 11:05am, V2 Director of Nursing confirmed R93 has not received nutrition via a feeding tube since July 2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to initiate a resident Care Plan for Oral Care for one resident for (R42) of 28 residents reviewed for Care Plans in a sample list of 48. Findings Include: R42's Functional Abilities and Goals admission assessment dated [DATE] documents Oral Hygiene Not Assessed. R42's Minimum Data Set (MDS) dated [DATE] documents R42 is moderately cognitively impaired and requires supervision to assist of one staff to complete ADLs (Activities of Daily Living). On 1/21/24 at 11:00AM R42 was seated in a wheelchair in R42's room. R42 had several front teeth missing and the remaining teeth were visibly crusted with debris. R42 stated I forget to brush my teeth sometimes, but I can eat ok. R42's Care Plan reviewed date 12/18/23 does not include a Care Plan addressing R42's missing teeth or his need for oral care. The facility provided a policy dated 1/2024 for Care Plan Meetings. However, this policy fails to address how the facility ensures individual resident…

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 remain free of a fire hazard for one (R39) of 28 residents reviewed for fire hazards from a total sample list of 48 residents. Findings include: The facility policy, K781, dated 7/1/2023 documents that portable space heaters and like devices are prohibited. R39's Minimum Data Set, dated [DATE] documents R39 as cognitively intact. On 1/21/24 at 9:30AM, R39's room had a space heater in use. The space heater was sitting on the counter, oscillating and blowing toward R39. On 1/21/24 at 9:31 AM V19, R39's Family Member stated it has been in (R39's) room for approximately a week. On 1/21/24 at 10:55AM, V2 Director of Nursing stated, The family brought the space heater into the facility. I told the husband they couldn't have it because it was a fire hazard. 1/21/24 11:00AM, V15 Certified Nursing Assistant stated, It (heater) has been in (R39's) room for about a week and a half. On 1/21/24 at 11:05AM, V1 Administrator said that space heaters are…

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 urinary catheter tubing and collection bag off the floor for one of two residents (R256) reviewed for urinary catheters on the sample list of 48. Findings include: On 1/21/24 at 12:27pm, R256 was seated in a wheelchair at a dining room table eating lunch. R256's urinary catheter tubing and collection bag were resting on the floor underneath R256's wheelchair. On 1/21/24 at 12:32pm, V3 Infection Preventionist stated R256's urinary catheter tubing and collection bag were absolutely an infection control issue resting on the floor. The facility Urinary Catheter Care Policy dated 3/2024 documents the following: to establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. Urinary drainage bags and tubing shall be positioned to prevent either from touching the floor.

Based on observation, interview and record review the facility failed to provide humidification as ordered for oxygen administration for one (R60) of one residents reviewed for oxygenation from a total sample list of 48 residents. Findings include: The facility provided Oxygen and Respiratory Equipment-Changing/Cleaning Policy, dated 8/2023, documents that oxygen humidifiers should be changed weekly or as needed and will be dated when in use. R60's physician orders dated 8/2/2023 document oxygen to be administered at 2.5 liters per nasal cannula with humidification. On 1/21/24 at 9:45AM, R60's oxygen was running at 2.5 liters per nasal cannula and the attached humidification bottle was empty, dated 1/14/24. On 1/21/24 at 12:30PM, R60's oxygen was running at 2.5 liters per nasal cannula and the attached humidification bottle remained empty, dated 1/14/24. On 1/21/24 at 12:31PM, R60 said that she had been asking for a new bottle of water for her oxygen for two days, And I still don't have one.

Based on interview and record review the facility failed to notify the physician of a resident not receiving a physician ordered IV (Intravenous) antibiotic medication for one of three residents (R1) reviewed for notification of changes in the sample of three. Findings include: The facility's Medication Errors and Adverse Drug Reaction policy dated 08/2023 documents, All medication, treatment, and drug reactions must be reported promptly. Notify the attending physician or medical director if the attending physician is not available. R1's Active Order Summary Report documents the following orders: Nafcillin Sodium Intravenous Solution Reconstituted (Nafcillin Sodium) use 12 grams intravenously in the evening related to Extradural and Subdural Abscess. 12 grams in 0.9 % (percent) NaCL (Sodium Chloride) 880 ml (milliliters) to be run over 24 hours. Flush each lumen of PICC (Peripherally Inserted Central Catheter) line with five ml of normal saline before and after infusion at bedtime. Order date: 10-20-23. R1's Progress Notes dated 10-27-23, 10-29-23, and 11-1-23 document R1's…

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

Based on interview and record review the facility failed to provide sufficient and competent staff (Registered Nurse/RN) to infuse a physician ordered IV (Intravenous) antibiotic 24/7 (24 hours a day/seven days a week) and to ensure a resident's PICC (Peripherally Inserted Central Catheter) infusion line and IV (Intravenous) pump remained patent (open and not blocked) for one of three residents (R1) reviewed for adequate staffing in the sample of three. Findings include: The facility's Facility Assessment Tool dated 08/2022 through 10/2023 documents, Purpose: The purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. The facility assessment must address or include the staff competencies that are necessary to provide the level and types of care needed for the resident population. Nursing Services-The facility must have…

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 infuse a physician ordered IV (Intravenous) antibiotic 24/7 (24 hours a day/seven days a week) for one of three residents (R1) reviewed for medication errors in the sample of three. Findings include: R1's Active Order Summary Report documents the following orders: Nafcillin Sodium Intravenous Solution Reconstituted (Nafcillin Sodium) use 12 grams intravenously in the evening related to Extradural and Subdural Abscess. 12 grams in 0.9 % (percent) NaCL (Sodium Chloride) 880 ml (milliliters) to be run over 24 hours. Flush each lumen of PICC (Peripherally Inserted Central Catheter) line with five ml of normal saline before and after infusion at bedtime. Order date: 10-20-23. R1's Progress Notes dated 10-27-23, 10-29-23, and 11-1-23 document R1's Nafcillin Sodium Intravenous Solution continuously by PICC line was not infused as ordered and these same notes do not include documentation of physician notification of R1's Nafcillin Sodium not being administered as ordered by the physician. On 11-10-23 at 10:35 AM V4 (Agency…

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 ten of 27 dressing changes to a diabetic ulcer as ordered for one (R1) of three residents reviewed for wound care in a sample of three. Findings include: R1's progress notes dated 6-22-23 document an open area to R1's left ankle was found. R1's July physician order sheet documents cleanse left medial ankle, apply silver hydrogel to wound bed, cover with foam, every day shift for wound healing. This order started on 7-7-23. R1's TAR (Treatment Administration Record) for July and August 2023 documents R1 did not receive his wound treatment on 7-12, 7-14, 7-17, 7-19, 7-21, 7-24, 7-26, 7-28, 7-31 and 8-2-23. R1 was sent to the hospital on 8-3-23. On 8-12-23 at 2:15 pm, V2 Director of Nursing, confirmed there was no documentation that this wound treatment was completed. V2 stated V9, agency nurse, was working those days and responsible for R1's wound care and was asked not to come back to facility due to failure to complete his work. On 8-14-26 at 10:50 am, E6 Wound Nurse stated on several occasions when completing…

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 sufficient staff to meet the needs for five of six residents (R1, R3, R4, R5 and R6) reviewed for staffing on the sample list of six. Findings Include: On 8/9/23 at 12:45 pm, V3 CNA (Certified Nursing Assistant) was working west wing with two other CNA's. V3 stated, this is typical lately, only having three CNA's when we use to have four on this wing. On 8/9/23 at 12:54 pm, V17 (R3's daughter) stated when R3 was admitted to the facility, R3 was able to walk better than (V17) could but due to not getting any restorative programs anymore, R3 is now in a wheelchair. R3's MDS (Minimum Data Set) dated 9/15/23 documents R3 has severe cognitive impairments, requires limited assistance of two staff for ambulation in R3's room and is in a walking restorative program seven days a week. On 8/9/23 at 1:50 pm, V4 LPN (Licensed Practical Nurse) working east wing stated V4 only has four CNA's today when they should have at least five. V4 stated it…

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 a clean homelike environment for three of three residents six residents (R3, R5, R6) reviewed for environment on the sample list of six. Findings Include: On 8/9/23 and 8/10/23 from 10:00 am - 2:00 pm, there were two housekeepers in the building working. On 8/9/23 at 12:54 pm, V17 (R3's family) stated housekeeping works hard but there isn't enough of them to keep the place clean. V17 stated R3's floor is sticky with stains. On 8/9/23 at 1:52 pm, V5 Houskeeper stated there are normally two housekeepers on east wing, two on west wing and one on the dementia unit but that V5 was working alone on the wing and has been working alone for over one month. V5 stated V5 is not able to get to every room everyday to clean but tries to at least get to each room to make their beds and pick up the garbage everyday. V5 stated V5 tries her best but it's too much. On 8/9/23 at 2:05 pm, R5 and R6 were sitting in their rooms. Crumbs and wrappers noted on the floor. R5 and R6 both stated housekeeping tries to come in…

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

Based on interview and record review, the facility failed to implement their Abuse Prevention and Reporting Policy by failing to complete a thorough investigation for one of three residents (R1) reviewed for abuse on the sample list of three. Findings Include: The facility's Abuse Prevention and Reporting Policy dated 10/2022 documents an incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Investigation Procedures: the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, the resident, if interviewable. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual. On 8/10/23, the facility's Abuse Investigation file for an abuse allegation between R1…

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 a thorough abuse investigation for one of three residents (R1) reviewed for abuse on the sample list of six. Findings Include: R1's undated Preliminary 24-hour Abuse Investigation Report documents on 7/28/23, R1 reported V18 CNA (Certified Nursing Assistant) was rough during cares. Employee immediately suspended. R1's Final Abuse Investigation Report dated 8/4/23 documents interview statements from R1, V9 CNA, V18 CNA, and V22 CNA but no interview statements from other residents, just a general statement of other alert and oriented residents were interviewed and voiced no similar interactions with (V18). The Alleged Abuse Witness Statements that were provided includes witness statements from an additional four staff between 7/31/23 and 8/1/23 but does not include any resident witness statements. On 8/10/23 at 10:18 am, V1 Administrator confirmed V1 was not able to find any resident interviews that were completed during R1 and V18's abuse investigation and there should have been. The facility's Abuse Prevention and…

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

Based on observation, interview and record review, the facility failed to provide services to prevent a decrease in Activities of Daily Living for one of three residents (R3) reviewed for restorative programs on the sample list of six. Findings Include: On 8/9/23 at 12:54 pm, V17 (R3's daughter) stated when R3 was admitted to the facility, R3 was able to walk better than (V17) could but due to not getting any restorative programs anymore, R3 is now in a wheelchair. R3's MDS (Minimum Data Set) dated 9/15/23 documents R3 has severe cognitive impairments, requires limited assistance of two staff for ambulation in R3's room and is in a walking restorative program seven days a week. On 8/10/23 at 5:00 am, V12 and V13 CNA's (Certified Nursing Assistant's) provided morning cares on R3 and got R3 up out of bed with a full weight bearing mechanical lift. On 8/10/23 at 8:40 am, V14 Restorative/CNA stated V14 use to be a Restorative CNA but now just works the floor as a CNA due to the facility cutting the restorative staff, approximately two weeks ago. V14 explained the facility expects 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 secure an indwelling catheter per plan of care and failed to keep the indwelling urinary drainage bag off of the floor for three of three residents (R1, R3 and R4) reviewed for catheters on the sample list of six. Findings Include: 1.) On 8/9/23 at 12:54 pm, V17 (R3's family) stated R3 has pulled R3's catheter out three times in the last two months due to it not being secured and the facility not keeping pants on R3. R3's August 2023 Physician Order Sheet documents an order to change the indwelling catheters securement device weekly. R3's Care Plan dated 6/2/23 documents R3 has an indwelling urinary catheter due to obstruction and hematuria with an intervention to ensure catheter tubing is secured with a securement device. On 8/10/23 at 5:00 am, V12 and V13 CNA's (Certified Nursing Assistants) were providing morning cares to R3. R3 was lying in bed with pajama pants on. As soon as V12 and V13 pulled R3's pants down, R3 reached down and started to grab at R3's indwelling catheter. R3 did not have a catheter…

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 protect the resident's right to be free from physical abuse by another resident. This failure affects two of six residents (R1, R2) reviewed for abuse in the sample list of six. Findings include: R1's Nurse's Note dated 7/13/2023 at 7:38 PM documents, Staff reported an allegation of resident to resident physical altercation. The facility's Final Abuse Investigation Report dated 7/20/23 documents on 7/13/23 that: R1 and R2 have diagnoses of Dementia. V3 witnessed R1 hitting R2 with a reacher/grabber. R2 was lying in R1's bed. R2 sustained a skin tear to the left hand. On 8/2/23 at 11:52 AM, V3 CNA stated on 7/13/23 at 7:30 PM, R2 was laying in R1's bed and R1 was hitting R2 with a grabber. V3 stated R1 was telling R2 to get out of her bed. V3 stated R2 sustained a skin tear to the left hand. On 8/2/23 at 1:30 PM, V1 Administrator stated he investigated the incident involving R1 and R2. V1 stated the investigation did conclude that R1 was hitting R2 with a reacher/grabber due to R2 being in R1's bed.

Based on observation, interview, and record review the facility failed to ensure cooking surfaces and dish storage areas were clean and free of cross contamination prior to continued use. This failure had the potential to affect all 121 residents residing in the facility all or most of whom consume food prepared in the facility kitchen. Findings include: On 12/12/22 at 9:05 AM, accumulated black and brown food residue was covering the doors to the oven. The base of the oven was covered with crumbs and food residue. Cooked rice and a large dried area of liquid was on top of the cook top griddle. V5 Dietary Manager stated the rice was from last night's supper. The stove's backsplash had accumulated dried food spattering stuck to it. The plate warmer which was full of plate warmers ready for use and had a thick covering of crumbs and dust. V5 stated stove and plate warmers are used for every meal. V5 confirmed the oven, stove, and plate warmer was dirty and stated those areas needed cleaned. The facility's census and condition report dated 12/12/22 signed by V4 Minimum Data Set…

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 hold QAPI (Quality Assurance and Performance Improvement) meetings at least quarterly. This failure has the potential to affect all 121 residents residing at the facility. Findings Include: The facility's Quality Assurance Sign-In Sheets document the facility held a meeting on 5/22/22 to cover the QAPI meeting requirement for January, February, and March of 2022, and a meeting 7/20/22 to cover the QAPI meeting requirement for April, May, and June of 2022. There is no documentation to support a meeting was held to cover the QAPI meeting requirement for July, August, and September of 2022. On 12/14/22 at 11:00AM V1, Administrator stated We were not able to have a QAPI meeting for the months of July, August, and September of 2022. We are working on scheduling one with our Medical Director of October, November, and December 2022. It is the policy of this facility to hold QAPI meeting at a minimum of quarterly. The facility's census and condition report dated 12/12/22 signed by V4 Minimum Data Set Specialist documents there are…

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 develop comprehensive care plans for four of 24 residents (R56, R58, R174, R117) reviewed for care plans in the sample list of 46. Findings include: The facility's Resident Care Policy and Procedure; Resident Assessment and Care Planning policy with a revised date of November/2017 documents, Each Resident's Care Planning needs will be met as presented in 483.21, Comprehensive Person Centered care planning of the State Operations Manual, Appendix PP. 4. The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs, as well as preferences for care an goals. This comprehensive care plan is person centered, and may be the continuation of the baseline care plan established within 48 hours of admission. 5. The facility must evaluate and modify, if necessary, the efficacy and appropriateness of each resident's care…

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 complete initial assessments prior to the start of psychotropic medications and quarterly, failed to justify PRN (as needed) psychotropics, failed to identify/track targeted behaviors, failed to document specific diagnosed conditions for psychotropic medications for six residents (R100, R95, R117, R21, R38, R329) of six residents reviewed for Psychotropic medication in a sample list of 46. Findings include: The facility's policy Psychotropic Medication revised 11/2817 states (psychotropic) medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, medical, behavioral, psychosocial needs.This policy also states Classifications of medication including: Antianxiety, Hypnotic, antidepressant medication. Initial PRN (as 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.

Based on observation, interview and record review, the facility failed to administer medications according to Physician's Orders for three of seven residents (R60, R79, R80) reviewed for medication administration on the sample list of 46 residents. The facility had five errors out of 25 opportunities for a medication error rate of 20%. Findings Include: The facility Medication Administration Policy dated 1/11/10 documents medications will accurately be administered following physician orders. Crush only medications that can be crushed or physician has given orders to crush. 1.) On 12/14/22 at 8:23 AM, V21 LPN (Licensed Practical Nurse) prepared R79's morning medications that included Metoprolol {Beta Blocker} ER (extended release) 50 mg (milligrams) tablet and Potassium 20 meq (milliequivalents) tablet. R79's Metoprolol had a warning on the medication card documenting take with meal or right after. R79's Potassium medication card contained a warning to take with food. After R79's medications were prepared, V21 entered R79's room and R79 was still lying in bed. V21 administered 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 interview and record review the facility failed to request a medication refill for one of one resident (R56) reviewed for significant medication errors. R56 did not receive 4 of 4 scheduled once weekly doses of diabetes medication as ordered by the physician. Findings include: The facility's Medication Administration policy dated 1/11/10 documents, 17. Missed doses of medication may occur at points in time related to lack of availability by suppliers, drug recalls, etc. In such cases, the facility will notify the contracted back up pharmacy or resident family (in cases where the family is the provider of these medications, such as is common with some insurance and VA {Veterans Administration} medications) for provision to the facility. R56's Order Summary dated 12/14/22 documents diagnoses including Central Dislocation of Left Hip, Subsequent Encounter, Muscle Weakness, Difficulty in Walking and Diabetes Mellitus. This Order Summary documents an order for Trulicity Solution Pen-Injector…

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 the call light response cord was within reach for three of 24 residents (R58, R44, R43) reviewed for accommodation of needs in the sample list of 46. Findings include: The facility's Call Light policy dated 8/1/05 documents, Objective: 1. To respond to resident's requests and needs. Policy: 1. It is the policy of this facility to maintain the highest quality of care for its residents. 7. Make certain call light is within resident's reach before leaving the room. 1.) R58's Order Summary dated 12/14/22 documents diagnoses including Bilateral Primary Osteoarthritis of Knee, Vascular Dementia, Mild, Postlaminectomy Syndrome, Muscle Weakness, Difficulty in Walking and Other Lack of Coordination. R58's Minimum Data Set (MDS) dated [DATE] documents recent spinal surgery and triggered falls to be carried over to the Care Plan. R58's Care Plan dated 11/18/22 documents to assist with ambulation and transfers. On 12/12/22 at 11:07 R58…

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 prevent misappropriation of one hundred and thirty three dollars for one (R49) of three residents reviewed for abuse on the sample list of 46. Findings include: R49's Quarterly Minimum Data Set assessment dated [DATE] documents that R49 is cognitively intact. On 12/14/22 at 9:03 AM, R49 stated my wallet was in my drawer and I had $133 dollars in my wallet. R49 pointed across the room and stated it was in the drawer over there. R49 picked up his wallet and opened it and there was no money in the wallet. R49 stated I had not spent my money on anything. I was needing some clothes and when I went and got it out of the drawer and opened my wallet my money was gone. I did not keep my money anywhere but in my wallet and I know for sure I didn't spend it. On 12/14/22 at 9:45 AM, V1 Administrator stated R49 reported that he had $133.00 that went missing. V1 stated R49 told him that he had his money in his wallet and when he looked for it and it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct care plan meetings with resident's and/or resident representative's for two of 46 residents (R44, R100) reviewed for care plans on the sample list of 46. Findings Include: 1.) R44's ongoing census report documents R44 was admitted to the facility on [DATE]. R44's MDS (Minimum Data Set) dated 11/24/22 documents R44 is alert and oriented. On 12/12/22 at 1:11 PM, R44 stated I don't know what you are talking about when asked if R44 was invited to the care plan meetings, and participated in them. At this time, V35 (R44's family) who was in the room with R44 stated V35 gets a letter about the care plan meetings, which were held over the telephone but that R44 was not a part of it. V35 stated she didn't realize R44 could be involved with the care plan meetings. On 12/13/22 at 12:21 PM, V12 Unit Coordinator stated the previous MDS Coordinators were suppose to send the care plan invites to residents and families but since they are no longer employed,…

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 prevent cross contamination of a pressure ulcer for one of five residents (R43) reviewed for pressure ulcers on the sample list of 46. Findings Include: R43's December Physician Orders document orders for the following pressure ulcer treatments: Right upper lateral ankle wound - cleanse with Normal Saline or Wound Cleanser, apply a mixture of Gentamicin ointment and Santyl {Chemical Debrider} to wound, then cover with thick absorbent gauze pad and secure with gauze wrap daily. Right lateral calf wound - Cleanse with Normal Saline or Wound Cleanser, apply a mixture of Santyl and Gentamicin ointment, cover with calcium alginate and a thick absorbent gauze pad and secure with gauze wrap daily and as needed. R43's Right lateral calf wound Culture dated 10/11/22 documents R43's wound has MRSA (Methicillin-Resistant Staphylococcus Aureus). R43's Wound Physician Notes dated 10/13/22 documents an unstageable (due to necrosis) pressure wound to the right upper calf measuring 6 cm (centimeters) by 4 cm x 0.3 cm, an…

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

Based on observation, interview and record review the facility failed to ensure that a knee immobilizer was in place as ordered for one of one resident (R56) reviewed for positioning devices in the sample list of 46. Findings include: R56's Order Summary dated 12/14/22 documents diagnoses including Central Dislocation of Left Hip, Subsequent Encounter, Muscle Weakness, Difficulty in Walking and Diabetes Mellitus. This Order Summary documents an order dated 11/4/22 that it is ok to remove knee immobilizer for bathing and dressing. R56's Therapy Discharge Communication dated 11/9/22 documents to apply splint to left lower extremity, on at all times except during cares and brace on over pants. On 12/12/22 at 10:53 AM, R56 was not in R56's room but R56's knee immobilizer was on R56's bed, not on R56. On 12/12/22 at 1:30 PM, R56 was in the common area in R56's wheelchair. R56's knee immobilizer was still on R56's bed, not on R56's left leg. On 12/13/22 at 10:02 AM, R56's knee immobilizer was on R56's bed, not on R56. On 12/13/22 at 3:06 PM V31, Registered Nurse stated R56's knee…

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 keep the indwelling urinary catheter collection bag and tubing off of the floor, failed to ensure the indwelling urinary catheter tubing was secure, and failed to prevent backflow of urine for two of two residents (R174, R27) reviewed for catheters in the sample list of 46. Findings include: The facility's Catheter Protocol dated 2/1/10 documents, 6. Catheter bags and tubing shall be maintained at a level below the bladder to prevent backflow of urine into the bladder. 7. The collection bag for catheters shall be emptied at least every shift. Care shall be taken to avoid contact of the drainage tube with anything that could contaminate it. 1.) R174's Order Summary Report dated 12/14/22 documents diagnoses including Other Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Vascular Dementia. This Order Summary documents an order for an Indwelling Urinary Catheter size 16 French/10cc (cubic centimeters) balloon, change every 30 days. On 12/12/22 at 10:59 AM, R174…

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 conservation, interviews, and record reviews the facility failed to employ sufficient kitchen staff to ensure the facility could clean the flat ware within enough time to serve meals without the use of plastic utensils for staff convenience. This failure impacts R327, one of 46 residents on the sample list. Findings include: R327's Care Plan initiated 12/5/22 documents the following diagnoses: Parkinson's Disease, Type II Diabetes, and Muscle Weakness. This Care Plan documents (R327) is at risk for nutritional problems related to diagnoses: Failure to Thrive, Parkinson's Disease, Hypertension, Lymphoid, Diabetes Mellitus, and other complicities. On 12/12/22 at 12:00 PM R 327 was seated in his recliner. R327's family member was visiting. R327's lunch tray was delivered to the room. R327 picked up a container of rice pudding and a spoon. R327 had apparent fine tremors to his hands as he scooped the pudding with difficulty to his mouth. R327's family member cut the pork loin on R327's plate. R327's family stated I try to be here at all of his meals, but Saturday evening…

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 state in the arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. They also failed to explain the arbitration agreement in a manner that the resident and their representative understands. This failure affects R15 and R60, two of 46 residents on the sample list. Findings include: The facility's Contract between resident and select facility has no documentation in the arbitration agreement that the agreement can be rescinded within 30 days of signing it, nor that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. R60's admission Contract dated 9/23/22 between R60 and the facility documents V28 (R60's family) signed the admission Contract and initialed the mediation/arbitration section of the binding arbitration. On 12/14/22 at 12:11 PM, V28 stated…

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 offer/administer Influenza vaccines for two residents (R17,R38) of five residents reviewed for immunization in a sample list of 46 residents. Findings Include: 1.) R17's Immunization consent signed by R17 on 9/26/22 documents I have been educated on the risks and benefits of receiving the influenza (flu) vaccine and I do want to be vaccinated annually. R17's immunization flow sheet documents R17 has not received the flu shot. R17's Minimum Data Set (MDS) dated [DATE] documents R17 is cognitively intact. On 12/12/22 at 10:00AM R17 stated I signed my consent for a flu shot, but I haven't got one yet. 2.) R38's Immunization consent signed by R38 on 11/7/22 documents I have been educated on the risks and benefits of receiving the influenza vaccine and I do want to be vaccinated annually. R38's immunization flow sheet documents R38 has not received the flu shot. On 12/14/22 at 10:00AM V7, Infection Preventionist stated Both (R17, R38) have consented for flu…

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.