Aperion Care Oak Lawn

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their practice to ensure that the Minimum Data Set assessment is accurately coded for four of four residents (R2, R46, R106, R116) reviewed for accuracy of MDS assessments. Findings include: 1. On 1/14/25 at 3:24pm V2 (Director of Nursing) said R46 was assess for hospice service and was not eligible for hospice services. V2 said R46 has never received hospice care while a resident at the facility. R46's Minimum Data Set/MDS section O for special services K1 for hospice dated 11/20/25 and 9/22/2025 shows X for hospice care performed while a resident at this facility. On 1/15/26 at 2:12pm, V21 (MDS Coordinator) said staff should ensure to code the MDS accurately to reflect the care for R46. 2. On 1/14/26 at 3:29pm, V16 (Restorative Nurse) said R116 is currently receiving restorative programing services 15 minutes a day, daily for range of motion to upper and lower extremity and bed mobility. Review of R116's MDS dated [DATE] section O for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their incontinence care policy by not providing incontinence care for over two hours for a resident as requiring substantial/maximal assistance with incontinent care. This affects one of three residents (R124) reviewed for incontinence care. Findings include:R124's Minimal data set dated [DATE] section C (cognitive patterns) document a score of eleven which indicate moderate cognitive impairment. Section GG dated 11/8/25 documents: R124 requires substantial/maximal assistance with toileting (helper does more than half the effort. Helper lifts or holds truck or limbs and provides more that half the effort.) Section H (bowel and bladder) dated 10/29/25 urinary continence document always incontinent. On 1/13/26 at 1:13pm, R124 was observed on the sit to stand device with the back of his jogging pants wet. R124 had a strong smell of urine. R124's wheelchair cushion was observed wet. V10 (Certified Nursing Assistant/CNA) said, R124 was soiled and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure supervision of a resident while smoking on the patio. The resident was identified as requiring supervision during smoking. This affected one of three residents (R22) reviewed for safe smoking monitoring. Findings include:R22 was admitted on [DATE] with a diagnosis of sickle cell, chronic obstructive pulmonary disease, type II diabetes, and major depressive disorder.R22's smoking safety risk dated 11/13/25 documents under smoking supervision recommendations documents: this resident requires supervision while smoking. Under the question does the resident display any of the following safety concerns? With nothing marked.On 1/13/26 at 1:34PM, R22 was observed in common dining. R102 was observed smoking on patio and upon reentering the patio assisted R22 to the outside patio and gave R22 a cigarette and lit the cigarette. R22 remained outside to smoke the cigarette. There were no staff on the patio monitoring or in the dining room…

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 its urinary care policy by not ensuring a resident's indwelling urinary catheter drainage bag was kept off the floor. This affected one of three residents (R72) reviewed for urinary catheter and infection control practices Findings include:Physician order dated 10/20/25 documents: Indwelling catheter for the diagnosis Neuromuscular Dysfunction of Bladder. R72's Minimal Data Set section H (bladder and bowel) dated 10/22/25 documents: indwelling catheter. On 1/14/2026 1:16 PM, R72 was observed sitting on the side of the bed eating his lunch with his indwelling catheter bag on the floor with the privacy bag not completely covering the top portion of the bag. On 1/14/26 at 1:17PM, V6 (Nurse) said, R72 indwelling catheter should not be on the floor. It should be attached to his bed frame. On 1/14/2026 at 1:25pm, V2 (Director of Nursing) said, indwelling bags should not be on the floor for infection control issue. Urinary Catheter Care dated 11/28/12 documents: To establish guidelines to reduce the risk of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its weight assessment and intervention policy by not conducting a reweight within 24 hours after a significant weight loss was noted. This deficient practice affected one of three residents (R88) reviewed for nutrition and weight loss prevention. Findings include:R88 was admitted to the facility on [DATE] with a diagnosis of dysphasia, muscle wasting, major depressive disorder and adult failure to thrive. R88's weights documents: October weight 132.5 pounds, November weight 132.8 pounds, December weight 132 pounds and January (1/9/26) weight 120 pounds (comparison weight 12/10 9.1 % loss, 12 pounds). There were no other weights documented in R88's medical record until 1/16/26 which documents 118.5 pounds after request was made by surveyor. On 1/16/25 at 10:00AM, V16(Restorative Nurse) said they conduct weights monthly and review any changes. If there is a big difference between the weight from last month either loss or gain we will reweigh 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 interview and record review, the facility failed to follow its abuse policy by failing to report an injury of unknown origin for a resident who was dependent on staff for Activities of Daily Living (ADLs). This failure affected one resident (R1) of three residents reviewed for injuries. Findings include:R1 has resided at the facility since August 2025, past medical history includes but not limited to Epilepsy, unspecified, other cerebral palsy, pressure ulcer of sacral region, unspecified stage, history of falling, other lack of coordination, dysphagia phase, essential primary hypertension, bipolar disorder, etc.On 10/16/2025 at 11:21AM, V3 (Family member) said, she discovered a black eye and bruises around R1's left eye when she visited the facility on 10/3/2025 and reported this to staff. The administrator said, staff saw R1 hitting her head on the table and caused the injury to herself. V3 added, R1 does not have such behavior and could not have done that to herself.On 10/16/2025 at 2:40PM, R1 was in…

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

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 initiate and thoroughly investigate an injury of unknown origin for a resident who is dependent on staff for Activities of Daily Living (ADLs). This failure affected one resident (R1) of three residents reviewed for injuries. Findings include:R1 has resided at the facility since August 2025, past medical history includes but not limited to Epilepsy, unspecified, other cerebral palsy, pressure ulcer of sacral region, unspecified stage, history of falling, other lack of coordination, dysphagia phase, essential primary hypertension, bipolar disorder, etc.On 10/16/2025 at 2:40PM, R1 in the dining room sitting at the table, awake and alert but non-verbal, just smiled at greeting. Resident is unable to answer any questions, staff stated that she was sleeping and just woke up. R1 no longer had any visible bruising or discoloration around her eyes, none observed in her arms.Minimum Data Set (MDS) assessment dated [DATE]…

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 a home like environment by not implementing an effective remedy to fix a leaking toilet, that caused water damage to the wall in the residents' room. This affects 4 of 4 (R3, R4, R9, R6) residents reviewed for sanitary home like environment.Findings include:On 7/1/25 at 8:00am V1 (Certified Nursing Assistant/CNA) said the toilet in R3 and R4's room is leaking. V1 said the bathroom is a shared bathroom between two resident rooms. V1 said she observed this on her second day working at the facility on 6/10/25.Review of the facility census and touring the facility demonstrated R3, R4, R6, and R9 share the bathroom.On 7/1/25 at 10:01am during a tour with V4 (Maintenance Director) there was a white sheet on the floor. V4 removed the sheet, flushed the toilet, the toilet is observed leaking at the base. V4 said the wall that extends into R3 and R4's room is damaged from the water leaking. V4 said he repaired that toilet in April 2025. V4 agreed that the repair was not effective because the toilet continued 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.

Based on interview and record review the facility failed to follow their abuse policy procedures and prevent a resident-to-resident physical abuse. This affected two of five residents (R3, R4) reviewed for abuse. This failure resulted in R4 slapping R3 in the face after R3 backed into R4 with a wheelchair. Findings include: 1.)R4's diagnoses include schizoaffective disorder bipolar type. R4's (3/28/25) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). R4's (10/21/24) care plan states resident has the potential to be physically/verbally aggressive related to poor impulse control, interventions: when the resident becomes agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. 2.) R3's diagnoses include schizophrenia. R3's (10/2/24) care plan includes risk for abuse, interventions: observe resident when in company of peers. R3's (6/3/25) BIMS determined a score of 15. The 5/2/25 initial facility reported incident states R3 was scratched by R4. Facility staff were present and intervened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who were dependent on staff for care were provided with showers according to the facility protocol and residents' preference. This failure applied to eight (R1, R2, R3, R4, R6, R7, R9, and R12) of twelve reviewed for showers during the month of March 2025. Findings include: 1. R1 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses that include and are not limited to hemiplegia and hemiparesis, hypertension, and chronic diastolic heart failure. Per the Minimum Data Set (MDS) dated [DATE], R1 needs substantial/maximal assistance, helper does more than half the effort during shower activity. On 3/29/2025 at 10:00 am R1 wrote in a notebook, I am very unhappy because I do not receive the showers on Wednesday's, Saturday's or when I request them, I do not like to be dirty and smelly. On 3/30/2025 at 10:00 am, V2 (Director of Nursing/DON) said R1 shower schedule days are Wednesday and Saturday 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 ensure resident safety by failing to have two staff members present when providing a mechanical lift transfer. This failure affects one (R4) of three residents reviewed for fall prevention program. Findings include: On 3/18/25 at 12:20PM, V2 (Director of Nursing) said that when alleged incident with R4 occurred V6 (Certified Nursing Assistant/CNA) had placed the Mechanical lift sling on backwards and R4 slid out onto the floor. V6 was doing a mechanical lift transfer for R4 by herself. On 3/18/25, at 12:27pm, V4 (Licensed Practical Nurse/LPN) said that he was called to the room by other staff members V5 (LPN) and V6 (CNA) and when he entered the room observed R4 on floor next to Mechanical lift machine. V4 said that Mechanical lift transfers are supposed to be a two person transfer assist. On 3/18/25 at 1:12PM, V5 (LPN) said that she was the nurse on duty for the alleged incident with R4. She heard a scream coming from R4's room and when she entered 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 interview and record review, the facility failed to follow their abuse policy and employee handbook by having a staff member accept gifts that were purchased by a resident. This affected one of three residents (R2) reviewed for abuse. Findings Include: R2 is a [AGE] year-old with the following diagnosis: cerebral palsy, paraplegia, epilepsy, neuromuscular dysfunction of the bladder, and bipolar disorder. The Police Report dated 10/22/24 documents R2 related that R2 is lending money to V12 (Certified Nursing Assistant/CNA) at the facility and that it was a verbal agreement. This is civil in nature. There are no other details on what gifts were given to the staff member or the amount of money. The Facility Reported Incident dated 10/22/24 documents R2 alleged that V12 misappropriated resident funds. R2 stated R2 was upset that V12 was not available to be the assigned CNA. R2 reported providing V12 with multiple gifts. V12 was educated by the administrator that no staff member can accept gifts of any sort…

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 Food Storage (Dry, Refrigerated, and Frozen) Policy by not labeling 2 bowls of gelatin with the date which has the capacity to affect 109 residents on an oral diet. The facility also failed to maintain resident personal refrigerators which affected 2 of 2 residents (R42 and R106) reviewed for refrigerators of a total sample of 30. Findings include: 1. On 11/07/24 at 10:20 AM, surveyor and V15 (Dietary Manager) observed the walk-in refrigerator and noted 2 bowls of gelatin without any label or date. V15 immediately removed the 2 bowls and said the gelatin will be discarded. On 11-8-24 at 11:00 AM, V16 (Dietary Director) said the food label indicates when the food has been made and the staff can determine how long the food is good for. V16 said the unlabeled gelatin found in the refrigerator will be discarded. V16 said the facility has 109 residents on oral diets. Food Storage (Dry, Refrigerated, and Frozen) Policy (no date) documents: a. All food items will be labeled. 2. On 11/07/2024 at 10:54AM…

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 no intravenous medication and hazardous pesticides were left at resident's bedside. The facility also failed to follow physician order in implementing fall precaution measures. This deficiency affects all four (R10, R23, R37 and R52) residents in the sample of 30 reviewed for Residents' safety. Findings include: 1. On 11/7/24 at 12:19PM, Observed R10 on right side lying position in bed. Observed call light on the floor on the left side of the bed. No floor mat observed. R10 is admitted on [DATE] with admitting diagnosis listed in part but not limited to Transient ischemic attack and Cerebral infarction, Parkinson disease, Age related physical debility, Moderate protein calorie malnutrition, Stage 4 sacral pressure ulcer, Type 2 Diabetes Mellitus, Vascular Dementia. Fall assessment indicated she is at risk for fall. Most recent unwitnessed fall incident dated 7/29/24 in the bedroom. R10 was observed in the floor. R10 attempting to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate infection control practices in proper handling of oxygen & respiratory equipment. The facility also failed to ensure proper hand hygiene/handwashing is performed during resident care. This deficiency affects all eleven (R15, R23, R38, R42, R50, R52, R85, R93, R105, R124, R432) residents in the sample of 30 reviewed for Infection control. Findings include: 1. On 11/7/24 at 10:17AM, observed R23's nebulizer mask hanging from drawer without plastic covering or date and nebulizer machine on floor. On 11/7/24 at 10:17AM, V7(Restorative Nurse) said she is unsure if nebulizer mask should have a plastic covering, V7 said the nebulizer mask should not be hanging from dresser or touching the floor. On 11/7/24 at 11:04AM, V2 (Director of Nurse) said that all nebulizer masks should be covered when not in use and have labeling of date when the mask was last changed. Facility's Policy on Oxygen & Respiratory…

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 respond promptly to an activated call light for one of three residents (R33) reviewed for call light in a sample of 30. The facility also failed to ensure to knock before going inside the resident's room for one of one resident (R50) observed for privacy and dignity in a sample of 30. Findings include: 1. On 11/07/2024 at 10:14AM during observation, R33 was observed lying on her bed. R33 showed R33's phone indicating the facility's phone number on the top of the list with number 3 enclosed in a parenthesis and time across it as 9:47AM, which indicates that she has called the facility three times with the last call made at 9:47AM. R33's call light was observed within R33's reach and R33 was observed activating it at 10:15AM. On 11/07/2024 between 10:15AM - 10:30AM, eight staff were observed passing by R33's room but no staff stopped by to check on R33 and what R33 needs. On 11/07/2024 at 10:25AM, R33 was observed calling R33's daughter to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a residents call light was within reach for 2 of 4 residents (R10 and R232) reviewed for accommodation of needs in a sample of 30. Findings include: 1. On 11/7/2024 at 10:30am R232 was heard yelling for help upon walking in the room R232 was observed with a water pitcher that was spilling over in the bed. R232 said I can't find my call light and my water is going to spill, I need help. R232 call light was observed on the floor behind the bed. On 11/7/2024 at 10:35am V9(Licensed Practical Nurse) said the R232 call light should be within reach. On 11/7/2024 at 12:30pm V2 (Director of Nursing) said all call lights should be in reach of all residents. An order summary report dated 11/8/2024 indicates that R232 has a diagnosis of dysphagia oropharyngeal phase, need for assistance with personal care. A care plan dated 10/28/2024 with an intervention of encourage fluid intake. A focus of fall related to confusion, deconditioning, gait, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the advance directive is indicated in the resident's health records for one of one resident (R1) reviewed for advanced directives in a sample of 30. Findings include: On [DATE] at 12:15PM during observation, a list of residents with active DNR (Do not Resuscitate) was observed on the South nurse's station. R1's name was not observed on the active DNR list. On [DATE] at 1:00PM during record review, R1's clinical dashboard indicated R1 is full code status. R1's physician's orders indicated R1 has an order for full code. R1's care plan revised on [DATE] indicated R1 is full code, attempt resuscitation, CPR (cardiopulmonary resuscitation), including intubation and mechanical ventilation. R1's scanned documents indicated R1 has a signed DNR/Practitioner Orders for Life-Sustaining Treatment (POLST) form on [DATE] with Do Not Attempt Resuscitation/DNR and Selective Treatment marked. On [DATE] at 11:08AM during record review with V13…

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 standard care practice of utilizing minimal layer of linens and not utilize a disposable brief when using low air loss mattress to resident who has stage 4 pressure ulcer. This deficiency affects one (R10) of three residents in the sample of 30 reviewed for pressure ulcer management. Findings include: On 11/7/24 at 12:19 PM, Observed R10 on right side lying position in bed. R10 is on LAL (low air loss) mattress with flat sheet and cloth pad over the mattress. Called V3 (Assistant Director of Nursing) and showed observation made. R10 is wearing disposable brief. V3 said that she is not sure what is their policy regarding multilayers of linen in using LAL mattress. On 11/7/14 at 1:19PM, Informed V2 (Director of Nursing/DON) of above observation. V2 said, resident on LAL mattress should have only flat sheet over the mattress. R10 is admitted on [DATE] with admitting diagnosis listed in part but not limited to Transient ischemic attack…

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 physician order is followed for tube feeding administration. This deficiency affected 1 of 3 residents (R121) reviewed for tube feeding administration in a sample of 30. Findings include: On 11/7/2024 at 10:35 AM during facility round, observed R121 tube feeding bottle hanging on a pole but not connected to R121 and machine was off. R121 said he gets feeding during the day and staff puts it on. On 11/7/2024 at 10:37 AM, V8 (Registered Nurse) said feeding for R121 should have been on according to physician order. On 11/8/2024 at 11:15 AM, V2 (Director of Nursing) said physician order should be followed and feeding of R121 should have been on at 10AM. Order Summary Report: Diagnoses: Dysphagia, Oropharyngeal, Gastrostomy Status Enteral Feed Order every shift Administer via enteral feeding pump; (Brand Name Enteral Feeding) 1.5 70ml/hr x 20hrs; total volume 1400ml. Start at 10am Stop at 6am. Care Plan: R121 have a G tube in place and at risk for complications related to use. Intervention: Tube feeding as…

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

Based on observation, interview, and record review the facility failed to ensure the medications are stored safely, securely, and properly following manufacturer/supplier recommendations. This deficiency affects one (1) of two (2) medication storage rooms and one (1) of three (3) medication carts reviewed for Medication Storage. Findings include: On 11/7/24 at 12:34 PM, observed East side hallway medication cart opened with keys attached to cart lock and unattended. On 11/7/24 at 12:36 PM, V15 (Licensed Practical Nurse) said that medication carts should not be opened, the medication carts should be locked when not in use. V15 said if the nurse on duty goes to break then the cart key is given to the other nurse on duty for safe keeping. On 11/7/24 at 12:37 PM, V15 opened East side medication cart and three (3) medication cups were observed with pre-poured medications unlabeled. V15 said that no pre-filled medication cups should be left inside the medication cart. On 11/7/24 at 12:42 PM, V15 opened East side medication room storage and medication room refrigerator lock was observed…

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 the building's call light system was operational. This failure affected 26 residents residing on the North Hall Unit of the facility. Findings include: On 9/12/24 at 1:13pm R3 said that R3 activated the call light from bed and waited longer than usual before calling the front desk for assistance. A staff member then told R3 that the call light system was malfunctioning. R3 said the call lights did not begin working again until the following day. On 9/16/24 at 10:06am V5 (Maintenance Director) said that the call light system was down for the whole building when V5 arrived to work that morning of 9/2/24. V5 said V5 was not notified that the system was down the previous day on 9/1/24 and have since created a step-by-step guide for the nurses to reset the system manually should it happen again. V5 said due to the building having older systems, when a storm or power surge occurs, the call light system is at times affected and requires a fuse to be reset. On 9/12/24 at 4:05pm V6 (Wound Care Coordinator) said V6 received…

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 investigate an allegation of abuse and neglect. This failure affected two (R3 and R4) of three residents reviewed for abuse. Findings include: R3 is [AGE] years old and admitted to the facility 8/24/23 with diagnoses that include osteoarthritis, morbid obesity, and chronic respiratory failure. According to the minimum data assessment of 8/5/24, R3 is dependent on staff for activities of daily living including toileting. On 9/12/24 at 1:15pm R3 was observed to be alert and coherent sitting in bed and described an incident that occurred with a CNA (Certified Nursing Assistant) on 9/1/24. During this interview, R3 said the CNA (V4) failed to answer requests for assistance when R3 activated the call light which prompted R3 to call the front desk from R3's cell phone. R3 said that R3 waited longer and shared this complaint to a family member who also called the facility to ask for assistance on behalf of R3. R3 reported that they were having severe…

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 to ensure a resident was treated with dignity and respect for 1 of 3 residents (R5) reviewed for dignity in the sample of 10. The findings include: R5's facility assessment dated [DATE] show R5 has no cognitive impairment. On 9/6/24 at 9:30 AM, R5 was sitting in her wheelchair in the dining room. R5 said V13 (Certified Nursing Assistant/CNA) ignores her request to be put to bed by 8 PM. R5 said she was up early and just wants to go to bed by 8 PM because by then she is very tired. R5 said she had requested to V13 (CNA) more than once to put her to bed but V13 still puts her to bed around 9:30 PM. R5 said it makes her feel upset that V13 does not listen to her request. This bothers me a lot. On 9/6/24 at 11:30 AM. V13 (CNA) said V13 is R5's CNA on 3PM-11PM shift. V13 said V13 puts R5 to bed after the evening meal but cannot recall the exact time. When asked if R5 had been being put to bed around 8:00 PM as per R5's request, V13 again said V13 put R5 to bed but…

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 venous doppler ultrasound was performed in a timely manner for a 1 of 3 residents (R3) reviewed for quality of care in the sample of 10. The findings include: R3's Face Sheet shows that she is [AGE] years old with a diagnosis of chronic pulmonary embolism (blood clot in lungs). On 9/6/24 at 10:00 AM, R3 said that on a Friday she started having swelling in both of her legs and some pain. R3 said that she spoke to the nurse and the nurse said that she was going to have an ultrasound of her legs to make sure she did not have any blood clots since she has a history of a blood clot in her lungs. R3 said that they did not come to do the ultrasound until Tuesday and when they got results, she was sent to the hospital because the test came back showing she had a blood clot in her leg. On 9/6/24 at 10:08 AM, V14 (Licensed Practical Nurse) said that on Saturday (8/10/24), R3's legs were swollen, and she had pain in her legs. V14 said that she called 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 ensure a gait belt was applied while transferring a resident safely. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 10. The findings include: R1's face sheet shows she is a [AGE] year-old female with diagnosis including schmorl's nodes lumbar region, type 2 diabetes, difficulty walking, muscle wasting and atrophy multiple sites, reduced mobility, malignant neoplasm of the breast, and personal history of radiation. On 9/6/24 at 10:10 AM, V6 (Certified Nursing Assistant) provided incontinence care to R1, she assisted her up in the bed, she stood R1 up from the bed without using a gait belt. R1 was unsteady, her right hand was holding to the right-side rail and her left hand stretched to grasping the wheelchair's arm. V6 was positioned behind the wheelchair away from R1, instructing R1 to turn, R1's feet shuffled, and her arms were shaking as she held on to the side rail and wheelchair arm, as she began to turn,…

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 medications were administered and not left at the bedside. This applies to 1 of 3 residents reviewed for medication administration in the sample of 10. The findings include: On 9/6/24 at 10:23 AM, R2 was not in her room, a medication cup with three pills were on her bedside table. R10 (R2's roommate) said the nurse's leave her pills at the bedside table frequently. Anyone can come in and take her medications. On 9/6/24 at 10:26 AM, V7 (Certified Nursing Assistant) said R2 is hard of hearing and forgetful. On 9/6/24 at 10:33 AM, V4 (Licensed Practical Nurse) said she is R2's nurse today. Medications should not be left at the bedside table, and nursing should make sure the resident takes the medication before leaving the room. V4 said she gave R2's medications this morning. This surveyor brought V4 to R2's room the medication cup with three pills were on her bedside table. V4 stated, I thought she took them. V4 said she charted the…

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

Based on observation, interview and record review, the facility failed to provide incontinence care at least every two hours. This affected one of three residents (R1) reviewed for incontinence care. This failure resulted in R1 observed being soaked with urine through her pants, skin redden with indentations. Findings Include: R1's brief interview for mental status dated 4/26/24 documents a score of 15/15 which indicated cognitively intact. R1's minimum data set section H bowel and bladder dated 4/26/24 under urinary incontinence documents always incontinent. On 8/1/24 at 3:22PM, R1 who was assessed to be alert and oriented to person, place, and time, said, she was soaking wet. R1said, she had not received incontinence care since 6:00am when she got up to the wheelchair. V8 (Certified Nursing Assistant/CNA) and V9 (CNA) was observed providing R1's incontinence care. R1 was lifted via the mechanical lift. R1 was observed with a wet spot on the back of R1's pants that covered her entire buttock and a puddle of fluid that smelled of strong foul urine on R1's wheelchair pad. V8 said…

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 the Centers for Diseases Control and Prevention (CDC) practices for Covid-19 by not requiring the appropriate use personal protective equipment (PPE) for residents on contact/droplet precautions and in isolation. This affected two of two residents (R10, R11) reviewed for infection control. Findings Include: R10's hospital paperwork dated 7/29/24 documents: R10 presented on 7/26 with altered mental status (AMS) now found to have Covid. Isolation: Contact, Droplet Infection. R10's face sheet documents: Covid-19. Physician order sheet dated 8/1/24 documents: Strict Isolation-Droplet and contact precaution-Covid +, every shift for ten days. R10's care plan dated 8/1/24 documents: I have a Covid Infection. On 8/1/24 at 2:39pm, R10 who had droplet precaution signage on the door that documents keep door closed was observed with her door crack open. On 8/1/24 at 2:40pm, R11 was seen coming out of R10's isolation room. On 8/1/24 at 2:45pm, R11 who was assessed to be alert and orient to person place and time,…

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

Based on observation, interview, and record review the facility failed to follow their incontinence care policy for one resident who was identified as dependent on staff for assistance with toileting. This failure resulted in R3 being cold, wet, and uncomfortable in urine. This affected one of three residents reviewed for incontinence care. Findings Include: R3 has the diagnosis of vascular dementia, hemiplegia and hemiparesis following cerebral infarction affection left dominant side. Brief interview for mental status dated 4/5/24 documents a score of fifteen which indicate cognitively intact. Section GG (functional abilities) documents: R3 was dependent for toileting hygiene (helper does all the effort) resident does none of the effort to complete activity. R3's care plan dated 3/17/22 documents: he has bowel and bladder incontinence. Check and change per facility protocol and assist with toileting as needed. On 6/7/24 at 9:59am, R3 who was assessed to be alert and orient to person, place and time said, the last time he was provided incontinence care was on the night shift. R3…

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 physician orders by not drawing weekly Keppra levels and failed to follow pharmacy recommendations for administrating Keppra tablets by crushing the tablets for one (R6) of three residents reviewed for medications and physician orders. Findings include: R6 was admitted to the facility on [DATE] with a diagnosis of seizures. R6's laboratory result for Keppra was documented on 4/19/24 with a level of 4.67. A level of 4.6 is considered nontherapeutic. Reference range is 10-40. Review of R6's medical record does not document any other Keppra levels. On 6/11/24 at 11:06AM, V42 (Medical Doctor) said R6's seizure medication (Keppra) levels are being monitored weekly. I would expect them to be done weekly as ordered to ensure the level is therapeutic. If the result is subtherapeutic, we would increase the dose and recheck the level to ensure it is therapeutic because she is at risk for seizures and an abnormal low result may result in seizures. V42 said…

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 utility rooms were maintained in a safe, clean, and sanitary condition. This has the potential to affect all the facility staff and residents residing in the facility. The findings include: The Facility Data Sheet signed on 2/4/24 showed there were 119 residents residing in the facility. On 2/4/24 at 1:06 PM, V1 (Administrator) said the Maintenance Director, nor the Director of Housekeeping were available for an environment tour. V1 (Administrator) accompanied the surveyor. At 1:14 PM, V1 (Administrator) unlocked the East clean utility room. There was a small sink area and countertop with 3 sets of cupboards below and one set of cupboards above the counter, to the right of the sink. The doors of all the cupboards were hanging off the bracket, in a diagonal manner. The doors of the cupboard were not closed. V1 had to maneuver each cupboard door to shut them. V1 said she will have to have Maintenance fix the doors. The upper cupboard held individual containers of resident bathing supplies. V1 closed 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 interview and record review the facility failed to ensure a resident was free of misappropriation of controlled medications for 1 of 3 residents (R3) reviewed for misappropriation in the sample of 8. The findings include: R3's Face sheet dated 2/4/23 showed diagnoses to include, but not limited to alcoholic cirrhosis of the liver with ascites (swelling around the abdomen), CHF (Congestive Heart Failure), liver cell carcinoma, encounter for chemotherapy, Stage 3 chronic kidney disease, and tobacco use. R3's Census List dated 2/4/24 showed he was admitted to the facility on [DATE] and was hospitalized from [DATE] to 12/1/23. R3's Controlled Drug Administration Record for Tramadol 50 mg - 1 tablet by mouth every 6 hours PRN (As needed). There were doses signed out by V14 (Licensed Practical Nurse/LPN) on 11/24/23, 11/26/23, and 11/27/23. (R3 was not in the facility). On 2/4/24 at 2:02 PM, V14 (LPN) said controlled medications are counted before and after each shift. V14 said the nurses should count any…

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 controlled substances were administered, documented, and reconciled appropriately for 1 of 3 residents (R3) in the sample of 8. The findings include: R3's Face sheet dated 2/4/23 showed diagnoses to include, but not limited to alcoholic cirrhosis of the liver with ascites (swelling around the abdomen), CHF (Congestive Heart Failure), liver cell carcinoma, encounter for chemotherapy, Stage 3 chronic kidney disease, and tobacco use. R3's Census List dated 2/4/24 showed he was admitted to the facility on [DATE] and was hospitalized from [DATE] to 12/1/23. R3's Controlled Drug Administration Record for Tramadol 50 mg - 1 tablet by mouth every 6 hours PRN (As needed). There were doses signed out by V14 (Licensed Practical Nurse/LPN) on 11/24/23, 11/26/23, and 11/27/23. (R3 was not in the facility). This document showed 30 tablets of R3's Tramadol were signed out from 11/11/23 to 12/23/23 (Only 4 doses were documented on R3's MAR). This…

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 safe and sanitary food service by not ensuring kitchen area and surfaces are clean and free of contamination, not properly storing dried food, not properly storing food handling equipment, not properly wearing hair restraints, not performing hand hygiene when necessary, and not measuring cooked food temperatures. This failure has the potential to affect all 122 of 125 residents in the facility who receive their food from the kitchen. Findings include: On 10/10/2023 at 10:00 AM observed multiple empty white containers stored in cooler with particles and unclean appearance. V12 (Dietary Manager) stated the white containers were for storing a medical supplement. Observed V12 remove white containers. V12 stated she was removing the white containers because they are not clean. Observed food prep/storage table with clean dishes to be unclean and with particles. V12 stated the food prep/storage table should be thoroughly clean. On 10/11/2023 from 10:47 AM - 11:42 AM observed…

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

Based on observation, interview, and record review, the facility failed to properly care and treat one resident with a urinary catheter and prevent development of repeated urinary tract infections. This failure applied to one (R59) of one resident reviewed for incontinence care. Findings include: R59 has multiple diagnoses including but not limited to the following: CHF (Congestive Heart Failure), type II Diabetes Mellitus, COPD (Chronic obstructive pulmonary disease), dysuria, UTI (Urinary Tract Infection), retention of urine, CKD (chronic kidney disease) III, and obstructive and reflux uropathy. On 10/10/23 at 11:05AM, R59 was interviewed regarding care within the facility. Observed R59 to have a catheter in place with amber colored urine draining. R59 said he is in a lot of pain in his penile area and would rate it at a nine out of ten currently. Observed R59 yelling out in pain and attempting to call the front desk to ask for his nurse on duty. R59 said he is not sure why he still has a urinary catheter in and wants it to be removed. Says he gets chronic UTI's ever since it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to ensure that staff follow their medication administration policy of ensuring that resident have their medications available as ordered and failed to ensure that staff do not borrow medications from one resident to another. The facility also failed to properly document medication administration of medication(s) on the controlled drug records for residents. This failure affected five residents (R35, R65, R91, R102 and R115) reviewed for medication administration. Findings include: 1.) R115's current diagnoses include but are not limited to: Type 2 Diabetes Mellitus with Diabetic Nephropathy and Acute Kidney Failure with Tubular Necrosis. On 10/10/23 at 10:29 AM, medication administration was observed for R115 with V4 (Registered Nurse/RN). V4 RN prepared R115's medications. V4 stated, R115 is out of the Lyrica, it was ordered yesterday. V4 did not administer R115's Lyrica. V4 documented a progress note which said the Lyrica is on order. R115'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 appropriately date open insulin pens and multi-dose insulin vials, and dispose of expired insulin for 7 (R13, R29, R53, R82, R111, R114 and R131) of seven residents reviewed during the medication storage and labeling observation. The facility failed to ensure a medication was stored in the pharmacy container with the pharmacy label while on the medication administration cart and failed to maintain the medication refrigeration temperature log to record temperatures daily. These failures have the potential to affect 31 residents on (name of unit) including the 7 residents who receive insulin. Findings include: On 10/10/23 at 11:56 AM, medication storage was reviewed with V7 (Licensed Practical Nurse/LPN). 1.) R114's Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 unit/ml (milliliters) (Insulin Glargine) is open and undated in the medication cart. V7 (LPN) stated, The date the insulin was opened is missing. The physician orders indicate inject 7 unit subcutaneously one time a day related to Type…

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 a resident's lost clothing was recovered and failed to reimburse a resident's family for the missing clothing as documented in the grievance form. This failure affected one (R51) of two residents reviewed for personal property. Findings include: R51 has resided at the facility since 2017, past medical history includes but not limited to essential primary hypertension, major depressive disorder, Alzheimer's disease with late onset, chronic kidney disease stage 3, dysphagia oropharyngeal phase, etc. 10/10/23 at 12:50PM, R51 was observed in her room in her wheelchair, awake and alert and stated that she is doing okay, said that she is hungry and was eating some popcorn from her drawer. Resident appears clean and appropriately dressed for the weather, staff redirected resident to go and eat at the dining room. 10/11/2023 at 10:39AM, V1 (Administrator) said that stated that one of the family members for R51 (V24) contacted her about resident's missing clothing, she believes housekeeping is looking for them, she does…

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 follow their policy and procedure for bathing residents as scheduled. This failure applied to one (R85) of one resident reviewed for assistance with activities of daily living. Findings include: R85's diagnoses include but not limited to the following: metabolic encephalopathy, pneumonia, type II DM (diabetes mellitus), severe protein calorie malnutrition, muscle wasting, difficulty walking, lack of coordination, cellulitis of abdominal wall, ESRD (end stage renal disease), and CHF (congestive heart failure). Per 85's Minimum Data Set (MDS) Section C dated 9/25/23 shows that resident has a Brief Interview for Mental Status (BIMS) of a 15, meaning resident is cognitively intact. On 10/11/23 at 10:15AM, R85 was interviewed regarding care within the facility. R85 said I have a large skin condition on my stomach that causes me pain. When I bump it or when I am moving around, my pain is between seven or eight out of ten. This skin condition happened because they did not give me a shower for three weeks. The CNAs (Certified Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedures for monitoring constipation for a resident with a history of constipation and fecal impaction. This failure applied to one (R2) of 26 residents reviewed for nursing care. Findings include: R2's diagnosis includes history Non-infective Gastroenteritis and Colitis, Hypothyroidism, Constipation, Polyneuropathy, Vascular Dementia, and Need for Assistance with Personal Care who was admitted to the facility 07/25/23. R2's MDS (Minimum Data Set) assessment dated [DATE], documents that R2 has a BIMS of 13 (indicating intact cognition). On 10/10/23 at 11:28 AM R2 stated she has been hospitalized [DATE]. R2 stated when she was at the hospital, they asked her how she had so many feces. R2's progress note dated 10/6/23 3:45 PM documents she was observed awake lying in bed talking to family member on the phone. R2 stated she didn't feel well. R2 complained of dizziness. Family member requesting for R2 to be sent out to 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 follow their pressure ulcer prevention policy by not immediately assessing an alteration to the residents' skin. This failure applied to one (R1) of three residents reviewed for pressure ulcers and resulted in a delay of four days before R1's skin was assessed after skin alteration was identified. Findings include: R1 was admitted to the facility on [DATE], with past medical history of hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, neuromuscular dysfunction of bladder, dysphagia following other cerebrovascular disease, type 2 diabetes, acute and chronic respiratory failure with hypoxia, etc. 10/10/23, resident was observed from 11:10AM to 12:20PM in her room lying on her back. R1 was awake and alert and stated that she is doing okay, G-tube infusing at 70ml/hour, oxygen via nasal canula at 2 liters ongoing. 10/11/23 at 10:00AM, R1 was observed in her bed lying on her back, strong odor of feces…

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 five percent (5%) or lower medication error rate. There were four medication errors out of 28 medication opportunities resulting in a 14% medication error rate. This failure affected two (R81, R115) residents reviewed during the medication administration task. Findings include: 1.) On 10/10/23 at 10:11 AM, V4 (Registered Nurse/RN) prepared medications for R81. R81's MAR Medication Administration Record indicates Folic Acid Oral Tablet 1 MG (Folic Acid). Give 1 tablet by mouth one time a day for Supplement. V4 stated, The 1,000 mg is out, so I'm giving the 800 mcg. V4 RN administered Folic Acid 800 mcg (micrograms) to R81. V4 administered the wrong dose of Folic Acid prescribed by the physician. R81's physician orders indicate Folic Acid Oral Tablet 1 MG (Folic Acid). Give 1 tablet by mouth one time a day for Supplement. R81's MAR indicates Sennosides-Docusate Sodium Tablet 8.6-50 MG. Give 1 tablet by mouth two times a day for Constipation. V4 (RN) administered Sennosides 8.6 mg only to R81. V4 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 orders for a coccyx and left heel treatment for one of four residents (R2) reviewed for pressure ulcers in a sample of four. Findings include: Facility Skin Condition Assessment and Monitoring/Pressure and Non-Pressure Policy, effective 11/28/12, documents: to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented; dressings which are applied to pressure ulcers and wounds, shall include the date of the licensed nurse who performed the procedure and the dressing will be checked daily for placement, cleanliness and signs and symptoms of infection; and Physician ordered treatments shall be initialed by staff on the electronic Treatment Administration Record after each administration. R2's Physician Order Sheet, dated 8/26/23, documents a treatment order to R2's Coccyx (cleanse with Normal Saline Solution, pat dry, apply ointment (brand name) and cover with…

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.