Alta Rehab At Oak Brook

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide feeding assistance and timely incontinent care to dependent residents. This applies to 2 of 4 residents (R1 and R4) reviewed for activities of daily living (ADL) care in a sample of 4. The Findings Include: 1. R1 is a [AGE] year-old male admitted on [DATE] with an admitting diagnosis, including cervical spine myelopathy. The MDS (Minimum Data Set) assessment dated [DATE] documents that R1 has intact cognition. R1's Physician Order Sheet (POS) dated 10/17/24 documented that R1 is on a regular, thin-liquid diet, with one to one feeding. On 10/31/24 at 8:45 AM, R1 stated, I need feeding assistance; they just started feeding me yesterday. Before, I was like a dog, putting my face on a plate to eat what I could get like a dog. I don't have a good grip on my hand. My condition deteriorated from cervical myelopathy. On 10/31/24 at 11:10 AM, V3 (Certified Nursing Assistant/CNA) stated, If a resident is a feeder, it should be on the diet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy ensure resident and family grievances are promptly resolved. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for assistance with ADLs (Activities of Daily Living) in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, lymphedema, hypertension, morbid obesity, polyosteoarthritis, bursitis of right shoulder, depression, noncompliance with medical treatment, candidiasis of skin and nails, uterine cancer, and functional urinary compliance. R1's MDS (Minimum Data Set) dated July 8, 2024 shows R1 is cognitively intact, requires setup assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, and is dependent on facility staff for toilet hygiene, showering, lower body dressing, bed mobility,, and transfers between surfaces. R1 is always incontinent of bowel and bladder. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to develop resident-centered care plans. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for resident rights and policy and procedure in the sample of 4. The findings include: 1. On September 16, 2024 at 11:20 AM, R1 was lying in bed in her room. R1 said her incontinence brief was wet and no staff had changed her brief since 2:00 AM. V5 (Agency CNA-Certified Nursing Assistant) said she reported for duty at the facility at 9:30 AM, was assigned to care for R1, and had not changed her incontinence brief during the time she had been on duty. V5 continued to say she had never worked with R1 and was not familiar with R1's care preferences, including if R1 requires assistance with turning in the bed, or has incontinence or skin care concerns. V6 (CNA) and V7 (WCN-Wound Care Nurse/RN-Registered Nurse) entered the room to assist with R1's incontinence care. R1 was very particular regarding her positioning during the incontinence…

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 promptly respond to call lights when a resident required assistance, failed to provide timely incontinence care, failed to provide feeding assistance as ordered by the physician, and failed to provide showers/bed baths as shown in the facility's policy. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for assistance with ADLs (Activities of Daily Living) in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, lymphedema, hypertension, morbid obesity, polyosteoarthritis, bursitis of right shoulder, depression, noncompliance with medical treatment, candidiasis of skin and nails, uterine cancer, and functional urinary compliance. R1's MDS (Minimum Data Set) dated July 8, 2024 shows R1 is cognitively intact, requires setup assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, and 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 observation, interview and record review, the facility failed to discard outdated food items and maintain the kitchen in a manner that prevent food borne illness. This applies to 108 of 109 residents serviced by the dietary services. Findings include: 1. On 7/16/24 at 10:10 AM, the kitchen was toured with V4 Dietary Manager. On 7/16/24 at 10:29 AM, the vent covers over the stove were covered with grease and lint / dust. On 7/16/24 at 10:32 AM, the covered meat slicer had smears of grease on the blade and crust on slicers base. On 7/16/24 at 10:35 AM, V4 Dietary Manager stated testing logs were not maintained for the three sanitizing buckets. On 7/16/24 at 1:17 PM, V5 Dietary Staff stated the kitchen staff was responsible for maintaining the unit refrigerators cleaning, discarding outdate items, and the temperature logs. On 7/16/24 at 1:30 PM, V4 stated the same sanitizer that is used for the three-compartment sink is used for the disinfecting buckets. V4 stated the policy the facility follows for the three-compartment sink applies to the sanitization buckets. The label on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to place residents' call lights within reach. This applies to 2 of 2 residents (R41, R58) assessed for accommodation of needs in a sample of 23. The findings include: 1. On July 16, 2024 at 1:20 PM, V37 (R41's Family Member) said when she arrived at the facility, R41 was sitting in the wheelchair and her call light was behind her, out of reach. V37 said her biggest concern was the staff would put R41 in the chair and the call light was not in reach, and she wanted her mother to be able to call for help. On July 17, 2024 at 2:05 PM, V37 said she noticed the housekeeping staff do not put the call light within reach of R41 after making the beds and felt the facility staff should attach the call light to the wheelchair. On July 18, 2024 at 9:14 AM, R41 was lying in bed and V39 (LPN/Licensed Practical Nurse) and V30 (CNA/Certified Nurse Assistant) were providing care for R41. After providing care, V39 and V30 left R41's room, and R41's adaptive…

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 reassess a resident for an appropriate-fitting device who had a hand wound; failed to ensure skin prevention interventions were implemented for a resident with a known behavior of scratching; and failed to check blood glucose levels prior to a resident eating or wipe the first drop of blood. This applies to 2 of 3 residents (R58, R61) reviewed for quality of care in a sample of 23. The findings include: 1. The EMR (Electronic Medical Record) showed R61 had multiple diagnoses including encephalopathy, dementia, and anxiety. R61's MDS (Minimum Data Set) dated 7/05/2024 showed R61 was dependent on facility staff for activities of daily living (ADLs). On 7/16/2024 at 10:41 AM, R61 was assisted back to bed after his shower for dressing by V17 (Certified Nurse Assistant/CNA). R61 had dressings to his left hand and right anterior thigh; and an open area to his left anterior thigh. V17 said she noticed R61's left thigh open area that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent a resident's decrease in range of motion. This applies to 1of 3 residents (R36) reviewed for range of motion in a sample of 23. Findings include: R36 was admitted to the facility on [DATE]. R36's primary diagnoses include acute kidney failure, gastro-esophageal reflux disease, hyperlipidemia, major depressive disorder, hypertension, gout, dementia and poly-osteoarthritis. On 7/17/24 at 1:58 PM, R36 was lying in bed and her left hand was contracted; R36 was unable to extend the fingers of her left hand. R36 stated she did not have a splint for her hand. On 7/17/24 at 2:02 PM, V6 C.N.A (Certified Nursing Assistant) stated R36 did not have hand splint on her plan. On 7/17/24 at 2:06 PM, V7 Restorative Nurse stated when R36 was admitted to the facility, she should have had an OT (Occupational Therapy) and PT (Physical Therapy) assessment. The assessments direct the staff on how she transfers and the care assistance she requires. V7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to act on the pharmacy MRR (Medication Regimen Review) and provide documentation monthly MMR. This applies to 2 of 5 (R44 and R52) residents reviewed for unnecessary medications and Monthly MMR in a sample of 23. Findings include: 1. R44 was admitted to the facility on [DATE]. R44 has diagnoses that include dementia with anxiety and agitation, hyperlipidemia, psychosis, major depressive disorder, osteoporosis, and repeated falls. R44 is currently being followed by hospice and has a physician's order for DNRCC (Do Not Resuscitate Comfort Care). The pharmacist MRR for R44 dated 1/10/24 states resident on psychotropic therapy Mirtazapine 7.5mg at bedtime since 2/2/23. Pharmacist request for physician review for GDR, such as discontinue Mirtazapine via gradual taper and document if any change in therapy is contraindicated. V43 MD written response No changes. Continue Mirtazapine on 3/18/24, more than two months after MRR was submitted by pharmacist. 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 prime an insulin pen prior to administration. This applies to 1 of 3 residents (R58) reviewed for significant medication error in a sample of 23. The findings include: On July 17, 2024 at 8:17 AM, V25 (LPN/Licensed Practical Nurse) was observed during medication pass. V25 said he was going to administer 25 units of Humalog insulin and after cleaning the pen and attaching the needle, turned the pen to administer 25 units. V25 did not prime the insulin pen prior to administration. V25 then administered the 25 units of Humalog insulin to R58. On July 18, 2024 at 12:55 PM, V25 said you have to prime the needle before giving a dose using the insulin pen. On July 18, 2024 at 12:53 PM, V27 (LPN) said the procedure is to prime the insulin pen with two units of insulin prior to administration. On July 18, 2024 at 1:41 PM, V2 (DON/Director of Nursing) said the insulin pen should be primed with two units of insulin prior to administration. R58's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide dental services to a resident requesting and requiring dentures. This applies to 1 of 1 resident (R41) reviewed for dental services in a sample of 23. The findings include: On July 16, 2024 at 1:20 PM, V37 (R41's Family Member) said R41 had dentures that no longer fit and she had asked for a new set. V37 said a dental hygienist came to visit R41 and said she needed dentures, but no dentist came to see her. V37 said the visit happened two months ago. V37 said R41 was on a mechanical soft diet because she needed new dentures and had passed the swallow test to have a regular diet. On July 18, 2024 at 2:10 PM, V37 said a dental hygienist came in and cleaned and sanitized R41's dentures, gave her oral swabs, and tested out R41's dentures and said they were the wrong size and she needed to be seen by the dentist. V37 said R41 had a stroke, and she was told by the staff who assisted with testing her feeding ability that R41 could be seen by a dentist…

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 explain and obtain an appropriate arbitration agreement contract from a resident (R67) with impaired decision-making. This applies to 1 out of 5 (R67) residents in a sample of 23. The findings include: R67's Electronic Medical Record (EMR) showed R67 admitted to the facility on [DATE] with multiple admission diagnoses including dementia. R67's MDS (Minimum Data Set) dated 2/16/2024 showed R67 was severely cognitively impaired. On 7/17/2024 at 2:05 PM, R67 was in bed. R67 was confused and unable to engage in an interview. V13 (Registered Nurse/RN) said R67 was very confused and unable to make decisions. On 7/16/2024 at 3:55 PM V12 (Admissions Assistant) said she was responsible for obtaining arbitration agreement contracts for residents. V12 said she shows the residents or residents' representatives an arbitration video and at the end of the video she asks them if they want to sign or decline the arbitration agreement contract. V12 said if a 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 implement strategies and equipment to prevent pressure injury. This applies to 1 resident (R2) of 3 residents observed for prevention and treatment of pressure injury. According to the MDS (minimum data set) for R2, R2 was admitted to the facility January 9, 2024 with advanced dementia and requires moderate assistance with bed mobility and substantial assistance with all transfers. The facility provided records of R2's pressure injuries which shows R2 has a pressure injury to the left heel, diagnosed on [DATE]. The wound is described as unstageable. The wound assessment performed by the Wound Doctor, dated April 10, 2024, shows the wound as worsening. The wound assessment performed by the Wound Doctor, dated April 17, 2024, shows the wound as improving. On April 17, 2024 at 11:30am, R2 was in the dining room eating lunch. After lunch was finished, R2 was assisted to bed and was in bed at 1:00pm. R2 was positioned on turned to the right…

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 administer medications as ordered by the physician and failed to follow the facility's policy for medication administration. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for improper nursing care in the sample of 3. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 left the facility AMA (Against Medical Advice) on December 31, 2023. R1 had multiple diagnoses including periprosthetic fracture around internal prosthetic right knee joint, fracture of right tibia, bronchitis, sleep apnea, heart failure, atrial fibrillation, and heart disease. R1's MDS (Minimum Data Set) dated December 19, 2023 shows R1 was cognitively intact. R1 was able to eat with set up assistance, required partial/moderate assistance with oral hygiene, personal hygiene, and bed mobility, and substantial/maximal assistance with toilet hygiene, showering and dressing. R1 was occasionally incontinent of urine,…

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 a resident would be free from accident/hazards. This applies to 1 of 3 resident (R1) reviewed for accidents/hazards. The findings include: The facility's 12/21/23 Final Incident Report showed that R1 complained of pulsating right index finger pain on 12/11/23 that happened during mealtime. The Report showed the time the incident was reported was 12 noon. The Report then showed on 12/13/23, R1's right index finger was observed with increased swelling, redness/dicoloration and her MD ordered a hospital evaluation. The Report showed R1 returned from the hospital the same day, and per hospital report, resident with superficial burn of right index finger and she was to continue with her oral antibiotic. On 12/29/23 at 10:15 AM R1 was in her room, alert and in a wheelchair. R1 said she burned her right pointer finger (index finger) on a meal plate that was too hot but could not remember the date when the incident occurred. R1 said 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 9. R24 has multiple diagnoses which includes encephalopathy, chronic obstructive pulmonary disease with exacerbation, chronic respiratory failure with hypoxia and type 2 diabetes mellitus, based on the face sheet. R24's admission MDS (minimum data set) dated May 1, 2023 shows that the resident is cognitively intact and requires extensive assistance with most of her ADLs (activities of daily living), including personal hygiene. On May 8, 2023 at 10:27 AM, R24 was in bed, alert, oriented and verbally responsive. R24 was observed with accumulation of facial hair on her chin area. R24 stated that she wants the staff to shave her chin hair. V10 (LPN/Licensed Practical Nurse) was present during the observation and was aware of R24's request to be shaven. R24's active care plan effective since April 22, 2023 shows that the resident requires assistance with personal hygiene. During separate interviews held on May 10, 2023 which started at 11:53 AM, V3 (Director of Nursing) and V4 (Assistant Director of Nursing) both…

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 residents were not left exposed while in bed during the provision of incontinence care. The facility also failed to ensure that urinary catheter drainage bags are covered. This applies to 3 of 20 residents (R50, R192 and R193) reviewed for privacy in the sample of 20. The findings include: 1. R50 has multiple diagnoses which includes hypertensive heart disease with heart failure, dementia without behavioral disturbance, major depressive disorder, primary open-angle glaucoma (bilateral), and muscle wasting and atrophy, based on the face sheet. R50's annual MDS (minimum data set) dated April 2, 2023 shows that the resident is moderately impaired with regards to cognitive skills for daily decision making and requires extensive assistance from the staff with most of his ADLs (activities of daily living) including bed mobility, dressing, toilet use and personal hygiene. The same MDS shows that R50 is always incontinent of bladder function and occasionally incontinent of bowel function. On April 8, 2023…

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 discontinue and intervene when a resident began to exhibit signs of coughing, throat clearing and increased secretions while being fed. The facility also failed to provide feeding supervision to a resident requiring supervision during eating. This applies to 2 of 2 residents (R33 and R39) reviewed for aspiration precautions in a sample of 20. The findings include: 1. MDS (Minimum Data Set), dated 5/5/23, shows R33's cognition was severely impaired. Physician note, dated 5/4/23, shows R33's diagnosis included dysphagia/possible aspiration with food and dementia. The note shows R33 was evaluated after possible aspiration and coughing while eating lunch. Speech therapy and a pulmonary evaluation were ordered and a chest x-ray was performed. The note shows R33 required close monitoring. Nursing note, dated 5/4/23, shows R33's diet was downgraded from regular texture/thin liquids to mechanical soft/nectar thick liquids. Physician note, dated…

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

Based on observation, interview, and record review, the facility failed to ensure that the catheter tube and bag were not touching the floor and not positioned over the bladder. The facility also failed to provide urinary catheter care and failed to secured the catheter to the resident. This applies to 3 of the 4 residents (R53, R192, R193) observed for urinary catheter care in the sample of 20. The findings include: 1. Face sheet shows that R193 is 85 years-old, who has multiple medical diagnoses which include benign prostatic hyperplasia (BPH). On 5/08/23 at 12:30 PM, R193 was in the dining room sitting in his wheelchair with indwelling urinary catheter bag directly touching the floor. On 5/10/23 at 1:33 PM, V38, V39, V40, and V42 (All Certified Nursing Assistants/CNA) transferred R193 via mechanical lift from wheelchair to the bed. V42 placed the catheter bag on the floor while they were attaching the sling of the mechanical lift. As R193 was being lifter up by the mechanical lift from the wheelchair, V40 took the urinary bag from the floor and held it higher than R193's bladder…

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

Based on observation, interview and record review the facility failed to follow physician's order with regards to administration of continuous oxygen via nasal cannula. This applies to 1 of 1 resident (R11) reviewed for oxygen therapy in the sample of 20. The findings include: R11 has multiple diagnoses which includes chronic diastolic (congestive) heart failure, persistent atrial fibrillation, Alzheimer's disease, anxiety disorder, pleural effusion and COPD (chronic obstructive pulmonary disease), based on the face sheet. R11's quarterly MDS (minimum data set) dated April 25, 2023 shows that the resident is moderately impaired with cognition and requires extensive assistance from the staff with most of her ADLs (activities of daily living). R11's active physician's order showed an order dated April 27, 2023 for, continuous oxygen at 3 liter per minute via nasal cannula every day. On May 8, 2023 at 10:26 AM, R11 was in bed, alert and verbally responsive. R11 was observed with shortness of breath. R11 was receiving oxygen via nasal cannula at 4 liters per minute using an oxygen…

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 as ordered by the physician. There were 25 opportunities with 6 errors resulting in a 24% error rate. This applies to 2 of 7 residents (R193 and R391) in the sample of 20. The findings include: 1. The Physician order sheet (POS) shows R391 has diagnoses that includes acute respiratory failure with hypoxia, congestive heart failure, atrial fibrillation and seasonal allergies. On May 9, 2023 at 9:01 AM during medication administration observation of R391, V21 (Licensed Practical Nurse/LPN) prepared and administered multiple oral medications. V21 (LPN) stated she is not giving two anticoagulant medications due to a physician order to hold for three days. V21 did not mention any medication that would not be given because of unavailability. Upon reconciliation of medication administration, V21 had not administered Azelastine 0.1% nasal spray scheduled to be given twice a day (9:00 AM and 9:00 PM) and Metamucil 3.4 grams oral powder scheduled to be given twice a day (9:00 AM and 5:00 PM).…

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

Based on observation, interview, and record review, the facility failed to serve 2 Gram Sodium diets as ordered/planned to residents who had physician orders for the therapeutic diets. This applies to 3 of 3 residents (R27, R11 and R9) reviewed for therapeutic diets. The findings include: Facility Client List Report, dated 5/9/23, shows R27, R11 and R9 all had physician diet orders which included two gram sodium diet. Facility Daily Spread Sheet Week Three Monday, undated, shows residents with a 2 gram sodium diet order were to be offered/served either baked fish or roasted turkey on a bun. The Spread Sheet showed residents receiving general diets were to be offered stuffed shells with tomato sauce or bratwurst. 1. Face sheet, dated 5/9/23, shows R27's diagnoses included dementia, diabetes, atrial fibrillation, atherosclerotic heart disease, and essential hypertension. MDS (Minimum Data Set), dated 3/27/23, shows R27's cognition was severely impaired. On 05/08/23 at 11:45 AM during meal service, R27 received two cheese-stuffed shells with tomato sauce as her entree for lunch. R27's…

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

Based on observation, interview, and record review, the facility failed to assess a resident for self-administration of medications and obtain physician orders for resident medication to be at the bedside. This applies to 1of 1residents (R8) reviewed for medications in the sample of 29. Findings include: On 8/9/22 at 12:15 PM, in R8's room, there were 3 cups of medication stacked in each other on R8's bedside table. The medication cups had 4 round unlabeled medications. R8 said the nurse left medications for her to take earlier, but she was falling asleep, so she did not take the medications. On 8/9/22 at 12:58 PM, V4 (Agency Nurse) said R8 only gets Aspirin and Lisinopril in the morning. V4 said R8 told her she would take her medications after eating and R8 has no issues with taking her medications. V4 said I just come back to make sure she takes it, R8 takes her medications when she wants to. V4 said she does not usually leave resident's medications at the bedside; she makes sure they take their medications. On 8/9/22 at 1:28 PM, V1 (Administrator) said, we do not have anyone on 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.

Based on observations, interviews, and record reviews, the facility failed to effectively communicate with 2 out of 2 residents (R46 and R31) that do not speak or understand English, in a sample of 29. The findings include: 1. On 8/10/22 at 11:34am R46, a Chinese speaking only person, was in her room with V7 (Wound Doctor) and V5 (Wound Nurse). R46 was receiving wound care to a wound to the left side of her face. V5 said that R46 received 2 Tylenol extra strength at 10am for pain. V5 said that R46 speaks English and when V5 asked R46 twice was she in pain she nodded her head yes. V5 said that she doesn't know if R46 understood her, but she didn't believe she was in pain. V5 then called V13, R46's daughter, who asked her mother if she was in pain and according to V13 R46 denied pain. Then after the phone call V5 began wound care and asked R46 to turn her head to the right. She asked this of her twice and R46 did not do what was asked and showed a look of confusion on her face. Then R46 stood up and turned toward her right. V5 touched her and gestured to sit down and began cleaning…

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 Peripherally Inserted Central Catheter (PICC) line care and Midline care by not measuring the length of the external catheter and upper arm circumference upon admission. This applies to 2 of 2 residents (R148 and R151) reviewed for intravenous access site care in a sample of 29. Findings include: 1. R151 is an [AGE] year-old female admitted on [DATE]. On 8/9/22 at 12:36 PM, R151 was observed with a left upper arm PICC line with a dressing dated 8/3/22. Record review on Administration Documentation History Detail Report (ADHDR) for R151 documents that the facility didn't measure the length of the external catheter (PICC) and upper arm circumference upon admission on [DATE] (initially measured on 8/9/22). On 8/9/22 at 1:52 PM, V2 (Assistant Director of Nursing - ADON) stated, We are supposed to measure the length of the external catheter (PICC) and upper arm circumference upon admission. We didn't have the PICC line dressing change…

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 manage residents' pain during wound treatment for 2 of 2 residents (R46 and R53) reviewed for pain in the sample of 29. Findings include: 1. On 8/10/22 at 11:13 AM V5 (Wound Care Nurse) gathered supplies for the wound dressing change, performed hand hygiene, don gloves and informed R53 of the dressing change. V6 CNA (Certified Nurse Aide) had positioned R53 to her right side. V5 proceeded with the wound treatment to R53's sacral wound. While V5 was cleaning the wound, V6 asked if R53 was in pain, R53 said she was in pain and said ouch. V5 said I'm sorry, but continued to clean the wound. After that, V5 began applying treatment to R53's wound, V5 asked R53 was if she was fine or if she should wait before continuing the treatment. R53 said you can wait. V5 waited about 5 seconds and continued to apply treatment and completed the treatment. V5 and V6 repositioned R53; V5 gathered her supplies and garbage and washed her hands. V5 did not address or offer R53 pain medication during the wound treatment. On 8/10/22…

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 the observation, interview, and record review, the facility staff failed to follow the ordered food preferences regarding food choices for 1 of 29 residents (R196) reviewed for diets. Findings include: R196 is a [AGE] year-old male admitted to the facility on [DATE]. R196's diagnoses included but were not limited to sepsis, osteomyelitis left heals and foot, chronic kidney disease, type 2 diabetes, and hypertension. On 08/09/2022 at approximately 11:45 AM, during an initial tour of the facility, R196 was observed sitting in his room alert, oriented, and interviewable. R196 was eating pasta, and his meal tray was on his side table with mashed potatoes, gravy and a salad. R196 said he is a vegetarian and the mashed potatoes has a gravy that has meat in it. R196 said he had eaten a tomato sandwich without realizing it had meat in it. R196 said he tried to remove the meat part and eat it. However, R196 said he doesn't like the meat smell. R196 said he had been here only for a week, but has had meat served…

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 and interview the facility failed to serve food in a sanitary condition for 1 of 1 residents in a sample of 29. The findings include: On 8/9/22 at 12:30pm R41 was in his room with his lunch tray on his bedside table and his urinal, with a clear liquid in the urinal, was laying on its side next to the lunch tray. No food had been touched. On 8/9/22 at 12:30pm V10 CNA (Certified Nurse's Assistant) said I shouldn't have put his lunch tray down on his bed side table with his used urinal next to it because it is cross contamination and can cause infections. On 8/9/22 at 1:43 pm V2 - ADON (Assistant Director of Nurses) said, The lunch tray should not have been put on the table next to the urinal, because of infection control. The facility's Use of Bedpans, Urinals & Basins, no date, showed under Procedure 1. All bedpans and urinals will be stored in the drawer inside the washroom when not in use.