Aliya Of Oak Lawn

Based on observations, interviews, and record reviews, the facility failed to follow its policy and ensure that residents had physician orders for medications stored at the bedside and were assessed for self-administration of medications. This affected two of three residents (R1, R7) reviewed for self-administration of medications Findings include: On 3/29/25 at 10:16 AM, R7 was observed to have a bottle of refresh eye drops on bedside table. R7 stated that the nurses have been administering this medication to him twice a day since his admission to this facility. R7 stated that he is not able to self-administer this medication. R7 stated that he is waiting for the nurse to administer eye drops. On 3/29/25 at 3:00 PM, R1 was observed to have a container of oral antidiarrheal medication on bedside table. R1 stated that R1 has diarrhea intermittently due to medical condition and has asked the nurse to have medication ordered. R1 stated that when R1 asks for this medication, the nurse informs R1 that the facility does not have any antidiarrheal medication. R1 stated that R1's family…

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 have a functioning call light system and failed to develop an effective plan for the residents to call for assistance on the North unit, this affects 28 of 28 resident (R1, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, and R30) reviewed for functioning call system. Findings include: On 3/8/25 at 11:12am V4 (Administrator) stated the call light system is not working in the North unit. V4 stated the call light system has not been working for one week, and that the part to fix the issue has been ordered. V4 stated the facility has implemented hand bells, and frequent rounding for residents. 3/8/25 at 11:22am V1 (Maintenance Assistant) stated the call light system is not working and the call lights system on the North unit has not been working for 3 to 4 weeks. V1 stated there's an electrical issue, and it's bigger than replacing a part. V1 stated the facility has implemented frequent rounding and hand bells for the residents to use.…

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 the resident food preference for one of 3 residents (R2) reviewed for food preference not being followed. Findings include: On 3/8/25 at 9:21am R2 was observed in the bed, R2 stated he did not eat his meal. At 9:30am R2 observed alert to person, place, date, and situation. R2 stated he refuses to go hungry because the facility can't get his meal right. R2 stated when he requests the regular meal, he gets a salad (substitute), and when the aides bring the wrong meal. R2 stated someone comes reviews the menu with him daily and they continue to get it wrong. At 9:23am surveyor observed R2 breakfast tray with assist from V9 (CNA), V9 stated he was R2's aide, and R2 ate most of his meal. V9 retrieved R2 tray and there were two boiled eggs (uneaten), 2 slices of bacon (uneaten), unopened milk, bowl of hot cereal (uneaten) noted on R2's (tray that was being sent back to the kitchen). V9 said he stated R2 ate his meal because R2 usually eats his meal, V9 stated he did not review what R2 ate before he placed 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 observations, interviews, and records reviewed the facility failed to provide bathroom/toileting assistance to 2 (R1 and R8) dependent residents. This failure affected 2 of 3 residents reviewed for toileting assistance. The findings include: A. On 2/18/25 at 10:34AM R8's call light on, lit, beeping. At 10:39AM call light remains on. A staff member entered the room and R8's family requested assistance to take R8 to the washroom. Staff member left to get nursing assistance. At 10:40AM V4, Certified Nursing Assistant/CNA, entered R8's room and stated I got to get help and V4 left R8's room. At 10:53AM the surveyor asked V14, R8's family if they had been assisted. V14 stated the CNA said she is coming back she has to get help. R8 in the bed. At 11:04AM V14 stated we are still waiting, he (R8) has to have a bowel movement and they need 2 staff to help him. R8 stated yes, I gotta go. The call light has been turned off and is not lit or beeping anymore. The surveyor was standing outside of R8's room within…

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

Based on interviews and records reviewed the facility failed to monitor and provide supervision during a smoking break. This affected two of three residents (R2, R3) reviewed for supervision. This failure resulted in a resident to resident-to-resident altercation. The findings include: The facility reported investigation dated 2/6/25 states R2 and R3 were in disagreement and exchanged words. On 2/18/25 at 11:16AM R3 stated R2 didn't like what I was saying to her. R3 stated R2 was calling me a B*%ch N*&&#% (derogatory, cursing, racist words). R3 stated R2 was standing and lost her balance. R3 stated R2 did not fall but lost her balance. R3 stated I did not push her; I waved her hand out of my face. On 2/19/25 at 9:35AM R2 stated on Thursday 2/6/25 I was outside on the smoking patio, after the 1:00PM smoking time opened. R2 stated R3 came to me and stated he didn't like the way I treat him. R2 stated I told R3 to leave then, if you don't like it go and I was pointing to the door. R2 stated instead R3 came at me and lifted me by my shirt and threw me, I hit the wall and went running…

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 1. Label and date opened food in the freezer, 2. Follow their policy on use of hair restraints by staff entering the kitchen without putting on a hair net and failing to use a beard restraint while in the kitchen, 3. Maintain infection control by placing a pair of oven gloves and a package of gravy inside clean and sanitized pots in the food preparation area and clean a whisk used during meal preparation, 4. Follow their policy on use of standardized recipes by not using a recipe during food preparation for lunch, and 5. Follow their policy on maintaining the proper sanitation level in the three compartment sink. These failures have the potential to affect all 151 residents who receive oral meals from the facility's kitchen. Findings include: On 1/13/24 at 10:28 AM, during review of the freezer noted one clear bag of food with no label or open date. V4 Dietary Manager/DM was inquired of the bag. V4 DM stated, It's potatoes, I'm not sure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the pharmacy policy by not noting and implementing open date labels for five of five (R148, R410, R22, R24, R131) residents reviewed during medication storage and labeling task in the sample of 31. Findings include: On 01/14/2025 at 12:10 PM Surveyor conducted inspection of the 1st floor (middle side) medication cart. Undated medication, unopened insulin not properly stored in facility/medication refrigerator noted for five residents: R148 Lantus Solo Injection Pen 100unit/ML - No open date written as directed by protocol noted on medication. Not stored in appropriate facility/medication refrigerator per pharmacy policy for all unopened insulin. R410 Lantus Solo Injection Pen 100unit/ML - No open date written as directed by protocol noted on medication. Not stored in appropriate facility/medication refrigerator per pharmacy policy for all unopened insulin. R22 Lantus Solo Injection Pen 100unit/ML, and Humalog Kwik Pen 100/ML - No…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to follow their policy and procedures for medication administration by not ensuring residents received medication and treatments as ordered by the physician. This failure applied to three of three (R1, R2, R3) residents reviewed for medication administration. Findings include: R1 a [AGE] year old, male admitted to the facility 11/05/2024 with diagnoses history of pulmonary embolism and deep vein thrombosis, morbid obesity, Alcohol use disorder, diabetes, Hypertension, and left humerus fracture. On the (MDS) Minimal data Set assessment of 11/18/2024 section C the BIMS (Brief Interviewed Mental status) score was 12/15. On 12/05/2024 at 10:45AM R1 stated that he is not getting his Norco pain medication as ordered and facility does not have medication in stock. R1 stated the facility is only giving half of his dose. R1 said, also he is not getting some of his routine medication as ordered by the physician. R1 physician order state Norco medication is ordered…

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 a resident from being physically abused by another resident. This failure applied to two of two (R1, R2) residents reviewed for abuse. Findings include: R1 is a [AGE] year-old female with diagnoses listed in part with atrial fibrillation, chronic obstructive pulmonary disease, protein calorie malnutrition, heart failure and osteoarthritis. R2 is a [AGE] year-old male with diagnoses listed in part with bipolar disorder, major depressive disorder, vascular dementia, and history of violent behavior. V1 administrator and abuse prohibition coordinator was unable to be interviewed due to the administrator no longer being employed by the facility during the start of this investigation. Facility records show that on 9/21/24 at 12 PM, R2 hit R1 in the back of her head while in a group activity. On 10/16/24 at 12:30 PM, R1 stated, I was passing by and got hit in the back of the head. There were two other men (patients) that saw this. I ain't seen no…

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

Based on interview and record review, the facility failed to protect residents from mental abuse and intimidation by staff. This failure affected three of three residents (R2, R7 and R8) living in the facility at the time of this survey and reviewed for mental abuse. Findings include: R2, R7 and R8 were interviewed on 9/30/24 during a complaint survey conducted in the facility. These residents expressed concerns regarding staff telling the residents not to speak with the Survey Team or participate with survey activities during a licensure survey that was conducted in the facility from 9/9/24 to 9/12/24. R2, R7 and R8 asked to keep their identities confidential regarding this concern in fear that the staff would retaliate or refuse to provide care. At 3:45pm, R7 stated during the survey of 9/9/24, staff informed R7 not to speak with the State Agency surveyors. R7 stated, that when a nursing staff member is upset with R7, R7 don't get care as requested or the nursing staff takes longer to answer the call light. R7 stated when one staff is mad, staff tell the other staff members who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's phone was not stolen by a visitor of the facility. This failure applied to one (R3) of three residents reviewed for misappropriation of property. Findings include: R3 is a [AGE] year-old female who originally admitted to the facility on [DATE] and later discharged home on 9/6/2024. admission nurses note dated 8/16/2024 indicated resident is alert and oriented x(times) 3. Facility Reported Incident dated 8/23/2024 shows that R3 had reported their cell phone was missing and believes a visitor for another resident took it from her room. V9 (family member) stated they received a phone call from an unknown male that was attempting to access the passcode to R3's phone. V9 reported that V12 (family member) identified himself and was later found out to be R6's family member that was visiting the day of 8/23/24. On 10/1/2024 at 1:50PM, V9 was interviewed regarding incident on 8/23/24. V9 stated we kept calling R3's phone but she was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide activities to meet the need/interest of one resident (R4) who was bed bound with deformities. This failure affected one resident in a total sample of twenty-five residents. Findings include: R4 is a [AGE] year-old resident admitted to the facility on [DATE] with medical diagnoses including but not limited to: Multiple sclerosis, unspecified severe-protein malnutrition, and quadriplegia. Minimum Data Set (MDS) dated [DATE] documents Brief Interview for Mental Status (BIMS) score of 14 which suggests cognition is intact. MDS also documents R4 requires partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, and is dependent for cares with toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear and personal hygiene. On 09/09/2024 at 11:04 AM, R4 stated, she only has partial use of right hand. On 09/09/2024 at 1:23 PM, R4 stated, I used to paint which I love…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to follow their policy and resident care plan related to skin care and activities of daily living for one dependent resident (R4) to keep skin clean and failed to follow doctors' orders to administer three residents (R2, R16, R17) their prescribed medication. These failures affected four of four residents reviewed for improper nursing care in a sample of twenty-five. Findings include: R4 is a [AGE] year-old resident admitted to the facility on [DATE] with medical diagnoses including but not limited to: Multiple sclerosis, unspecified severe-protein malnutrition, and quadriplegia. Minimum Data Set (MDS) dated [DATE] documents Brief Interview for Mental Status (BIMS) score of 14 which suggests cognition is intact. Section GG documents R4 requires partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, and is dependent for cares with toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off…

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

Based on interviews and record reviews, the facility failed to follow its abuse prevention policy and report an allegation of physical abuse immediately. This affected one of three residents R1 reviewed for reporting allegations of abuse. Findings include: On 5/28/24 at 11:48 AM, V2 DON (director of nursing) was made aware on 5/16/24 of an allegation of physical abuse involving R1. The allegation involved staff hitting and pinching R1. V2 stated that R1 went to the hospital on 5/16/24. V2 stated that the hospital did not notify the facility of R1's allegation. V2 stated that R1 had a bruise on left arm on 5/15/24. On 5/29/24 at 10:15 AM, V1 (administrator) stated that V2 DON did not inform him of the abuse allegation involving staff hitting and pinching R1. V1 was informed that he was not present in the facility on 5/28/24 at 11:48 AM when V2 was informed of the allegation of abuse. V1 stated that V2 informed him that this surveyor had a concern for physical abuse but not an allegation of abuse involving staff hitting and pinching R1. R1's skin condition report, dated 5/15/24 at…

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 timely incontinence care for 1 of 3 dependent resident, R13 in a sample of 28 reviewed for activities of daily living. Findings include: On 4/9/2024 at 10:30am R13 informed this writer that she had been waiting all morning to for assistance with incontinence care and to be placed in her wheelchair, and no one had returned since bringing her breakfast tray. R3 stated the last incontinence care assistance had been at 4:30am when her blood glucose was obtained by the nurse. On 4/9/2024 at 10:40am V3(Assistant Director of Nursing-ADON) observed with the writer R13 hospital gown soaked from the waist down, the smell of urine, the depends on was soaked with dark urine and the bed linen wet with urine. On 4/9/2024 at 10:45am V3 stated this is not okay the nursing assistants should be making rounds every two hours and as needed. On 4/9/2024 at 10:42am V24(Lead Certified Nursing Assistant-CNA) stated I will assist R13 in cleaning up. V24 stated the CNA for R13 is in another resident room. The nursing staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement fall prevention interventions to a resident who is at high risk and with history of falls. This deficiency affects one (R20) of three residents in the sample of 28 reviewed for Fall Prevention Program. Findings include: On 4/9/24 at 11:10AM, V12 Restorative Nurse presented to surveyor list of residents on fall prevention program. V12 stated that R20 is at high risk for falls due to history of falls. R20 should be in lowest position when in bed for safety. On 4/9/24 at 11:16AM, rounds made with V12 Restorative Nurse to R20's room. R20 lying flat on bed in high position approximately 38 inches from the floor alone in her room. V12 stated that R20 should be in lowest position when in bed for safety and should not be left alone when the bed is in high position. V12 called the CNA (Certified Nurse Assistant) assigned to R20. V13 CNA stated that she placed R20 in highest position because she is preparing her to get up and left her…

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 sign the shift-to-shift controlled substance count sheet acknowledging that actual count of controlled substances and count sheet matches the quantity documented. This deficiency affects one (North Unit Medication cart 1) of four medication carts reviewed for Handling, Storage and Record Keeping of Controlled Substance. Findings include: On 4/9/24 at 11:06AM, Checked North medication cart 1 with V11 Licensed Practical Nurse (LPN). Narcotic and controlled substance shift to shift count sheet incomplete. Missing numerous nurse's signatures dated: 4/2/24- 2nd and 3rd shift; 4/3/24- 1st and 3rd shift; 4/4/24- 1st shift; 4/8/24- 1st, 2nd and 3rd shift. V11 stated that both nurses, off-going and on-coming, will sign after counting the narcotic/controlled substance count sheet. On 4/9/24 at 12:30PM, informed above observation to V3 Assistant Director of Nursing (ADON). V3 stated that the going off duty nurse and coming on duty nurse are to count all controlled drugs together at each change of shift and sign.…

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 monitor and document medication refrigeration temperature and failed to place date on tuberculin purified protein after opening as manufacturer recommendation. This deficiency affects both two medication rooms (West and North unit) reviewed for Safe Medication Storage. Findings include: On 4/9/24 at 9:31AM, Checked [NAME] unit medication room storage with V10 Licensed Practical Nurse (LPN). Used/opened not dated tuberculin purified protein 5ml vial. The vial has instructions to discard after 30 days from opening. V10 LPN stated that they should write the date after opening the tuberculin vial. On 4/9/24 at 11:23AM, Checked North unit medication room storage with V11 LPN. Actual medication refrigerator temperature is 40F read by V11 LPN. On April 2024 refrigerator temperature monitoring log was not recorded from 4/4, 4/6, 4/7, 4/8 and 4/9/24. V11 LPN stated that the night shift is responsible for monitoring and documenting the medication refrigerator temperature daily. Reviewed March 2024 Medication…

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 influenza, Pneumococcal and COVID immunizations as required to three of five residents (R21, R107, and R133) reviewed for immunization in a sample of 28 residents. Finding include: During record review on 4/11/2024 at 11:00 AM, R107 and R133' s immunization records did not indicate that these residents received or refused the Pneumococcal, Influenza and COVID vaccine. R21's immunization record indicated that she last received the Pneumococcal vaccination on 10/1/2022. There was no documentation of any given or refused of the vaccination. On 4/11/24 at 11:45am, and V2 (Director of Nursing) and V4 (Infection Prevention) both stated, all immunization given or refused should be documented. V4 stated that, she is responsible for checking that residents' s immunizations are up to date once admitted into the facility. V4 stated that she took over the position two weeks ago. On 4/11/23 at 1:45 pm, V2 and V15(Unit Manager) both stated that all residents…

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 and maintain an adequate amount of nursing staff to care for 33 residents who required minimal to moderate assistance on the short-term rehabilitation unit of the facility. This failure applied to one (R9) of one resident reviewed for nursing care and has the potential to affect 33 residents currently on the rehabilitation unit of the facility. Findings include: On 3/5/24 at 1:22PM R9 was observed receiving incontinence care from a CNA (certified nursing assistant). When finished, R9 told the surveyor that they had been admitted to the facility for about a week and had some concerns with receiving care in a timely manner. R9 specifically noted the past Saturday (3/2/24) was particularly bad because no CNA came to render incontinence care during the morning shift (6:30AM- 2:00PM) and they weren't seen until early evening. R9 said, that although the call light was repeatedly activated, staff would come into the room, and simply turn off the call light. Staff also scolded R9 saying that there wasn't enough staff 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 interview and record review, the facility failed to provide and document timely incontinence care for a resident dependent on staff for assistance with ADLs (activities of daily living). This failure applied to one of one (R9) resident reviewed for incontinence care. Findings include: R9 is an [AGE] year-old who admitted to the facility 2/26/24 after hospitalization for diagnoses of Adult Failure to Thrive and Left Hip Osteoarthritis. R9 entered the facility with a stage II pressure sore to the sacrum and facility staff assessed R9 to be incontinent of bowel and urine on admission. Progress notes in the electronic health record indicated that R9 was alert, cognitively intact and pleasant. On 3/5/24 at 1:22PM, R9 was observed lying in bed, receiving incontinence care by nursing staff. Immediately after care was rendered, R9 was noted to be alert and coherently aware. During interview R9 expressed how lack of staff over the previous weekend resulted in laying in urine and fecal excrement for several…

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 its abuse policy by failing to assess residents for abuse risk and failed to develop an abuse care plan for these residents. This failure affected five (R9, R10, R11, R13 and R16) of five residents reviewed for abuse. Findings include: R16 is a [AGE] year-old male who have resided at the facility since 3/20/2023, with past medical history of encounter for orthopedic aftercare following surgical amputation, other acute osteomyelitis right ankle and foot, type 2 diabetes with foot ulcer, hyperglycemia, diabetic nephropathy, sepsis unspecified, difficulty walking, hyperlipidemia, acute respiratory failure with hypoxia, etc. 1/18/2024 at 10:10AM, R16 was observed in his room, awake and alert and stated that he is doing okay, just tired today. R16 stated that he had an issue with a driver who was supposed to take him to dialysis, the driver refused to tell R16 his name when he asked, stating that R16 does not need to know his name, the driver handled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their room change/transfer policy and procedures by not ensuring a resident's representative was notified of a room change and not obtaining the resident representative's permission to change the resident's room. This failure applied to one of three residents (R19) reviewed for resident's rights. Findings include: R19 is a [AGE] year-old female with a diagnoses history of Legal Blindness, Disorders of Muscle, Convulsions, and Muscle Wasting and Atrophy who was admitted to the facility 07/21/2022. R19's Quarterly Minimum Data Set assessment dated [DATE] documents she has a basic interview for mental assessment score of 9. On 01/18/2024 at 12:45 PM observed R19 in her room sitting in her wheelchair dressed, with her hair combed into a ponytail in front of the television being assisted by V8 (Certified Nursing Assistant) while eating. V8 stated R19 has been in her current room for less than a year. V8 stated R19 was moved from another room close…

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 observations, interviews, and record reviews the facility failed to follow their policy and procedures for assistance with activities of daily living by not ensuring a dependent resident who is blind received assistance with grooming her hair, dressing, incontinence care, being transferred out of bed, and storing her clothing and belongings in an orderly manner. This failure applies to one of three residents (R19) reviewed for activities of daily living. Findings include: R19 is a [AGE] year-old female with a diagnoses history of Legal Blindness, Disorders of Muscle, Convulsions, and Muscle Wasting and Atrophy who was admitted to the facility 07/21/2022. On 01/17/2024 at 12:33 PM Observed a urine smell on the North unit where R19's room is located. V8 (Certified Nursing Assistant) stated R19 is blind. Observed R19 in her room lying in her bed in her gown eating. When asked by surveyor if R19 wants to get out of bed R19 stated she would like to. Observed R19's hair to be a slightly messy. V8 stated R19…

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 fall prevention policy by not implementing fall preventative measures per the president's plan of care. This failure applied to two (R1, R2) of six residents reviewed for accident/hazards. Findings include: 1.R1 is a [AGE] year-old with diagnoses of spinal stenosis, hypertension, cerebral infarction and hemiplegia. A facility reported incident report dated 11/27/2023 authored by V47 (LPN) reads in part, At 7:11 AM nurse observed patient sitting on the floor in front of her wheelchair. When asked what happened the patient stated that she slid off her wheelchair trying to open the door to the restroom. Patient has one-person limited assist with transfer and is incontinent of bowel and bladder. X-ray ordered and completed. MD notified of left hip X-ray report of impacted intertrochanter with various deformity. Patient sent to hospital. admitted with diagnosis of left displaced femoral neck fracture. On 1/17/24 at 12:50 PM, 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 observations, interviews, and record reviews, the facility failed to follow their policy and procedures for pain management by not examining a resident's newly reported pain in a timely manner, not performing, and documenting a pain assessment for newly reported pain, and not ensuring a resident received pain management as needed. This failure applied to one of three residents (R19) reviewed for pain management. Findings include: On 01/18/2024 at 2:42 PM Observed R19 moaning in pain and stating she's in pain while pointing to her upper abdomen. R19 stated she was hurting. On 01/18/2024 at 2:43 PM Surveyor informed V13 (Licensed Practical Nurse) of R19 moaning and reporting pain in her upper abdomen V13 stated she had just recently administered some pain medications to R19. V13 stated she will go and check on R19 but she's off the clock. V13 stated R19 had never reported this pain to her but she'll check up on R19 after she finishes counting medications with the oncoming nurse V28 (Registered Nurse). V28 confirmed she was aware of what the surveyor reported to V13 about…

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 observations, interviews, and record reviews, the facility failed to follow their dental care policy and procedures by not ensuring a resident received routine dental services to meet their needs. This failure applies to one of three residents (R19) reviewed for dental care. Findings include: On 01/18/2024 at 2:48 PM Observed R19 with a missing tooth, with multiple cavities, with some tarter buildup. R19 stated all her teeth are loose. On 01/18/2024 at 3:19 PM V2 (Director of Nursing) stated R19 does not have any record of being seen by the dentist and has no order to see the dentist. R19's admission assessment dated [DATE] does not document any abnormalities with her teeth. R19's Medical Practitioner Comprehensive assessment dated [DATE] does not document any abnormalities with her teeth. R19's current care plan does not include dental care. R19's medical records reviewed 01/18/2024 did not include a dental exam/evaluation. R19's progress note dated 01/18/2024 at 4:57 PM states the social worker spoke…

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

Based on observations and interviews, the facility failed to follow their policy and procedures for ensuring resident care equipment is in safe operating condition by not identifying a blind resident's wheelchair was in disrepair and in need of replacement. This failure applied to one of three residents (R19) reviewed for resident rights. Findings include: On 01/17/2024 at 2:10PM R19 stated when she's in her wheelchair her shoulder and neck hurts and her legs hurt as well. On 01/18/2024 at 12:45 PM Observed R19 in her room sitting in her wheelchair. Observed the back of R19's chair to be bent and lack supportive form/structure. On 01/22/2024 at 2:15 PM V49 (Family Member) stated R19 has dementia and is blind. V49 stated the back of R19's wheelchair is broken, and it was reported to the nurse a couple of times. V49 stated the social service worker assured R19's wheelchair would be taken care of, but nothing has been done. On 01/22/2024 at 3:03 PM V2 (Director of Nursing) stated 15 new wheelchairs have been ordered by the facility but had not yet been received. On 01/23/2024 at 12:30…

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

Based on interviews and record reviews, the facility failed to notify the resident's family or representative of wounds identified and/or update family on deteriorated wounds. This affected two of three (R10, R11) residents reviewed for notification of change. Findings include: On 10/26/23 at 11:15am, V22 (wound care nurse) stated that V22 is familiar with R10. V22 stated that R10 had a stage 3 left buttock pressure wound and a non-pressure wound to right lateral lower leg. V22 stated that R10 also had a wound to right buttock, that resolved in facility. V22 stated that she works Monday through Friday to perform wound care treatments for all residents with wounds. V22 stated that V22 rounds with V32 (wound care physician) on Tuesdays. V22 stated that V32 sees all residents with wounds weekly, except surgical wounds. V22 stated that the wound care nurse contacts the family if a new wound is identified, wound is declining, or new wound present on admission. V22 stated that the wound care nurse is supposed to chart in the resident's progress notes when family is updated. V22 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.

Based on interviews and record reviews, the facility failed to maintain complete and accurate medical records for two residents (R10 and R11) out of three reviewed for accuracy of documentation. Findings include: On 10/31/23 at 11:00am, V14 (wound care coordinator) stated that when wound care nurse takes photograph of resident's wound the program used will automatically note wound measurements. V14 stated that V32 (wound care physician) manually measures wound size. V14 stated that this is reason wound measurements don't always match up. V14 reviewed the wound care team notes and stated that it looks like V32 mixed up the wound sites, right buttocks, and left buttocks, when he documented. On 10/31/23 at 12:50pm, V14 clarified the sites of R10's left buttock and right buttock were switched in V32's (wound care physician) note dated 9/26/23. Review of V32's (wound care physician) note, dated 9/26/23, notes R10 with a stage 3 pressure wound of the right buttock measuring 7.2cm (centimeters) x 2.2cm x 0.2cm, 30% slough (yellow tissue) and 70% granulation (pink) tissue. R10 had a stage 3…

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

Based on interviews and records reviewed the facility failed to report an allegation of abuse for 1 (R1) who reported to staff she was drugged and raped. This failure affected one of three (R1) residents reviewed for investigation of abuse allegations. Findings include: R1's diagnosis includes but are not limited to Cognitive Communication Deficit, End Stage Renal Disease and Dependence on Renal Dialysis. On 10/4/23 at 2:14PM V8, Certified Nursing Assistant (CNA), stated on Saturday morning 9/30/23, R1 said she felt sleepy, she said they drugged her last night. V8 stated R1 told her this after breakfast. V8 stated when she handed R1 her dentures she was crying. V8 stated I told the nurse on duty that R1 said she was drugged. On 10/4/23 at 2:26PM V15, Registered Nurse, stated after dialysis, while getting R1 from her chair into bed, R1 was crying. V15 stated R1 said she was raped. V15 stated she was drugged and felt like she was drunk. V15 stated R1 was upset and crying. V15 stated R1 has never made accusations like this before. On 10/5/23 at 11:10AM V17, Nurse, stated no one…

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 who requires extensive assist of staff with ADLs (activities of daily living) received incontinence care. This applied to one (R3) of three residents reviewed for activities of daily living in the sample of five. Findings include: R3's face sheet shows she is a [AGE] year-old female with diagnosis including hemiplegia and hemiparesis following cerebral infarct affecting the left non-dominate side, malignant neoplasm of the colon, muscle wasting and atrophy and heart disease. R3's Minimum Data Set assessment dated [DATE] shows she's cognitively intact, requires extensive two person assist with toileting and frequently incontinent. On 9/22/23 at 9:11 AM, R3 was observed lying in bed. A strong permeating smell of urine was present. R3 said she was soiled and needed to be changed. I already told the staff early this morning, I needed to be changed. I was last changed last night. R3 pressed her call light for assistance. At…

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, interviews, and record reviews, the facility failed to follow their protocol related to use of low air loss mattresses used for the prevention of skin breakdown for four (R15, R16, R18 and R19) of five residents reviewed for pressure ulcers. Findings include: R15 is a [AGE] year-old, female, admitted in the facility on 06/13/20 with diagnoses of paraplegia, unspecified and pressure ulcer of Right hip, stage 4. Wound Evaluation and Management Summary dated 08/01/23 documented: stage 4 pressure wound of the Left ischium and stage 4 pressure wound of the Right hip. Plan of care indicated off-load wounds. Care plan on impaired skin integrity dated 07/25/23 recorded: Intervention: pressure redistributing support surface - low air loss mattress. On 08/07/23 at 2:10PM, R15 was observed in bed, alert, oriented. R15 stated she got the Left pressure ulcer because she had been laying too much on her Left side to offload the Right side because of the pressure ulcer. R15 is on a low air loss mattress.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure regarding fall management and failed to adequately assess one resident (R4) for their risk for falls. Findings include: R4 was an [AGE] year-old male who originally admitted to the facility on [DATE] and later expired on [DATE]. R4 has multiple diagnoses including but not limited to the following: osteomyelitis, depression, unsteadiness on feet, sepsis, abscess of Right foot, muscle weakness, subdural hemorrhage, muscle wasting, myocardial infarction, hyperlipidemia, HTN, emphysema, COPD, and CAD. Minimum Data Set (MDS) assessment dated [DATE] shows that R4 needed assistance with all Activities of Daily Living (ADL's) and was frequently incontinent of bowel and bladder. Facility Reported Incident dated [DATE] states in part but not limited to the following: R4 was observed on the floor close to his bed. Nurse on duty asked patient what happened and R4 stated I was using the urinal by sitting at the edge of the bed 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 implement hand hygiene during wound and incontinence care, failed to use PPE (Personal Protective Equipment), and failed to complete a resident COVID surveillance assessment. This deficiency affects all 6 (R1, R20, R63, R72, R135 and R136) residents in the sample of 19 reviewed for infection Control. Findings include: On 10/11/22 at 10:55am, no signage was observed at the entrance of the double door of COVID Airborne Isolation Unit (CAIU). There are 4 residents (R1, R72, R135 and R136) with positive for COVID infection in the unit. Surveyor observed R135's room does not have isolation cart in front of his door. Surveyor observed with V14 CNA (certified nursing assistant) that all 3 isolation carts in CAIU/COVID unit do not have face shield supplies. All 4 resident's rooms do not have an isolation hamper just garbage bin inside their rooms. On 10/11/22 at 11:00am, surveyor observed V14 come out of R1's room without disinfecting her face shield and proceeded to another resident's room on another unit. On 10/11/22…

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.

Based on observation, interview and record review, the facility failed to keep call lights within resident's reach for two (R68, R335) of six residents reviewed for call lights in a sample of 19. Findings include: On 10/11/2022 at 10:45AM, R68 was observed sitting in a wheelchair by the foot of the bed with his coccyx area at the edge of the wheelchair and upper back resting on the back of the chair. Call light was noted on the nightstand by the head of the bed. On 10/11/2022 at 11:13AM, R335 was observed lying in bed, call light was noted on the floor. On 10/11/2022 at 10:45AM, R68 and R335 were observed with V11 (Registered Nurse) and noted their call lights out of the residents' reach. V11 stated all call lights should be within residents' reach. On 10/11/2022 at 2:12PM, V2 (Director of Nursing) stated that all call lights are expected to be within residents' reach especially to the residents who need assistance with their ADLs (Activities of Daily Living). R68's Order Summary Report dated 10/11/2022 indicated admission date of 09/19/2022 and diagnoses not limited to sequelae 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.

Based on interview and record review, the facility failed to ensure that the resident's advance directive is reflected in the resident's medical record for one (R60) of five residents reviewed for advance directives in a sample of 19. Findings include: R60's Order Summary Report indicates admission date of 10/03/2022 with diagnoses of generalized anxiety disorder, chronic obstructive pulmonary disease, Parkinson's disease and atherosclerotic heart disease, and an order for Full Code with order date of 10/03/2022. Social Service Note dated 09/18/2022 indicated R60 remains a DNR. Do-Not-Resuscitate (DNR)/Practitioner Orders for Life-Sustaining Treatment (POLST) Form signed by Nurse Practitioner on 09/14/2016 indicated Do Not Attempt Resuscitation/DNR. On 10/13/2022 at 10:43AM, V29 (Social Service Director) stated that residents who have signed POLST form should have a physician's order reflecting their chosen treatment if it comes to a point that they are noted with no pulse and not breathing. Facility Policy: Title: Social Services Guidelines Advance Care Planning Code Status 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 interview and record review, the facility failed to develop and implement care plans for residents on antibiotic, anticoagulant treatment, and update a care plan for a resident with COVID infection for three (R1, R60, R335) of four residents reviewed for care plans in a sample of 19. Findings include: R60's Order Summary Report indicated admission date of 10/03/2022 with diagnoses of a urinary tract infection and an order for Cefdinir 300mg (milligrams) 1 capsule by mouth two times a day for UTI (urinary tract infection) for 10 days with order date of 10/03/2022. Care plan was reviewed and did not indicate R60 is on antibiotic treatment. R335's Order Summary Report indicated admission date of 10/06/2022, with diagnoses of embolism and thrombosis of deep veins of left upper extremity and an order for Heparin Sodium (Porcine) Injection Solution, Inject 1500 units subcutaneously every 8 hours for dvt (deep vein thrombosis) PROP (prophylaxis) with order date of 10/07/2022. Care plan was reviewed and did not…

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

Based on observation, interview and record review, the facility failed to follow physician order to apply TED (thromboembolic deterrent) hose for one (R335) of one resident reviewed for edema management in a sample of 19. Findings include: On 10/11/2022 at 11:13AM, R335 was observed lying in bed without knee high TED hose on. On 10/12/2022 at 12:35PM, R335 was observed with V11 (Registered Nurse) lying in bed without knee high TED hose on. On 10/12/2022 at 12:35PM, V11 stated that R335 should have a TED hose on as prescribed. R335's Order Summary Report indicated admission date of 10/06/2022, diagnoses of acute embolism and thrombosis of deep veins of left upper extremity and an order to apply knee high TED hose AM (morning) and remove for bedtime one time a day for edema/swelling with order date of 10/07/2022. Admit/Re-Admit Progress Note dated 10/07/2022 indicated pulses unable to palpate due to edema. General Progress note dated 10/07/2022 indicated R335 was seen by MD (Doctor of Medicine), new order received and knee-high TED hose for AM and remove for bedtime.

Based on observation, interview and record review the facility failed to ensure interventions for pressure ulcer prevention were implemented and failed to apply heel boots for 1 of 4 residents (R13) reviewed for pressure ulcers in a sample of 19. Findings include: On 10/11/2022 at 12:30pm R13 was observed in bed with heel protectors on the chair. On 10/11/2022 at 12:33pm V4(Certified Nursing Assistant-CNA) observed with surveyor, R13 in bed without heel boots. V4 stated he should have the boots on, I usually apply them at night. On 10/11/2022 at 2:30pm V2(Director of Nursing-DON) stated R13's heel boots should be on if he wants them on and the staff should follow the doctor's orders. An Order Summary Report dated 10/13/2022 indicated a diagnoses of difficulty walking, hemiparesis following unspecified cerebrovascular disease affecting right dominant side. A care plan dated 6/13/2022 with a focus of at risk for alteration in skin integrity, an intervention for off-loading boots to bilateral lower extremities BLE to be worn while in bed. ` Facility Policy: Skin Management Guidelines…

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 the indwelling catheter below the resident's bladder to prevent back flow of urine into the bladder. This deficiency affects one (R20) of three residents in the sample of three reviewed for urinary catheter management. Findings include: On 10/11/22 at 12:15pm after V15 LPN (Licensed Practical Nurse) and V18 CNA ( Certified Nurse Assistant) provided wound care to R20, V18 CNA picked up the catheter drainage bag and held it close to the resident's chest while trying to fix the cloth privacy bag. R20's urine from the drainage bag was observed back flowing into the tubing. On 10/11/22 at 2:31pm, Informed V2 DON (Director of Nursing) of above observation. V2 stated that indwelling catheter drainage bag should never be handled above the bladder of resident to avoid infection. R20 is re-admitted on [DATE] with diagnoses to include cerebral infraction, dysphagia following cerebrovascular disease (CVA), gastrostomy, metabolic…

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 physician orders in administration of oxygen to a resident. This deficiency affects one (R20) of three residents in the sample of 19 reviewed for oxygen management. Findings include: On 10/11/22 at 10:30am R20 was observed lying in bed without oxygen. R20's oxygen concentrator machine was observed off at bedside. R20 is non-verbal. On 10/11/22 at 11:40am, V15 Licensed Practical Nurse/LPN and V18 CNA stated that R20 is not using oxygen. R20 was re-admitted on [DATE] with diagnoses to include cerebral infraction, dysphagia following cerebrovascular disease, gastrostomy, metabolic encephalopathy, chronic kidney disease, dementia, history of COVID infection. R20's physician order sheet indicates oxygen via nasal cannula at 2 LPM (liter per minute) continuously, notify MD/NP (medical doctor/nurse practitioner) if oxygen saturation is below 92% every shift. R20's care plan indicates she has altered respiratory status/difficulty breathing…

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 dispose of expired medications from the North side medication room for one (R20) of one resident reviewed for medication storage and labeling in one of four medication rooms observed. Findings include: On 10/11/22 at 12:00pm during observation, the North Side medication room was observed with two [NAME]/Tazo 3.375g intravenous (IV) which expired on 8/14/22 and 10 [NAME]/Tazo 3.375g IV which expired on 8/17/22. During an interview on 10/11/22 at 12:00 pm with V2 (Registered Nurse), V2 stated that expired medications should be return to the pharmacy. During an interview on 10/11/22 at 2:15pm, both V1(Administrator) and V2 (Director of Nursing) stated that expired medication should be return to the pharmacy or discarded per policy. Facility's policy dated 5/4/22, Titled: Disposal/Destruction of Expired or Discontinued. Applicability. This policy 8.2 sets forth procedure relating to medication disposal and destruction. Procedure:4; Facility…

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.