Landmark of Oak Lawn Rehabilitation and Nursing Ce

Based on observation, interview and record review, the facility failed to account for the Shift change accountability record for controlled substances. This deficiency affects one of four medication carts (1st floor medication cart). Findings include: On 6/12/25 at 3:15PM, V5(Licensed Practical Nurse) said that controlled substance check is done daily on each shift with incoming nurse to verify narcotic count, V5 observed on controlled substance sing in sheet that dates were missing initials, said that the nurse did not sign. On 6/12/25 at 3:15PM, V6 (Licensed Practical Nurse) said that controlled substance is counted each day on each shift. V6 verified that there were dates with missing initials and said that if the initials are not there it does not mean the count was not done, V6 said she was not here on those dates. On 6/12/25 at 4:05PM, V2 (Director of Nursing) made aware of above findings with V5 and V6 of empty spaces not initialed in the days for 6/3/25, 6/10/25 and 6/11/25 and when asked to provide a copy of sheet the copy was given with all dates filled with initials. V2…

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 the medications are stored safely, securely, and properly following manufacturer/supplier recommendations. This deficiency affects one resident (R5) in a sample of three residents reviewed for Self-Administration of Medications by Residents. Findings include: On 6/13/25 at 10:29AM, R5 observed in room, inhaler laying on top of bedside table, no name or open date available. R5 said she is allowed to have it at bedside. On 6/13/25 at 10:35AM, V3 (Licensed Practical Nurse) said that residents are not supposed to have medications at bedside, but some can, V3 said she will check for order. On 6/17/25 at 11:07AM, V3 said all medication should be kept inside package so it can have the residents name, medication name and instructions, and date it was opened and stored in package for infection control purposes. On 6/17/25 at 11:31AM, V2 (Director of Nursing) said that the medication kept at bedside should be stored it the packaging sent from…

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 activity calendar and implement and engage the residents in social activities of tabletop games on 2/25/25 for 4 of 6 (R6, R7, R8, R9) residents reviewed for social activities. Findings include: On 2/25/25 at 11:25am upon entering the dining room on the second floor. V6 approached with surveyor. V6 introduced herself as the Activity's Director. V6 entered with the surveyor. V6 said she was coming to the second floor to see what activities was taking place. V6 said there were no activities going on. V6 said she does the activities with the residents. On 2/25/2025 at 11:25am V7 (CNA) and V8 (CNA) was observed in dining room, V7 said she was talking to a resident. V8 (CNA) said she was doing one to one monitoring with a resident. Board games were observed stacked up sitting the table. There were no staff observed engaging the residents with activities. R6 was observed in dining room with his head down on the table and not engaged by staff. R7 observed with his head down, not being engaged in social activities. R8…

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 appropriate care for residents with incontinence by not ensuring that incontinence care was provided at least every two hours. This affected one of three residents (R10) reviewed for incontinence care. This failure resulted in R10 being left soiled and saturated in urine for over five hours and feeling cold. Finding Include: R10 was diagnosis with hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, functional quadriplegia, reduce mobility and need for assistance with personal care. Minimal data set section C (cognitive pattern) dated 11/1/24 documents a score of twelve which indicates moderate cognitive impairment. Section GG (functional abilities) documents: R10 has impairments on one side to the upper and lower extremity. R10 is dependent (helper does all of the effort) for toileting hygiene. Section H (bowel and bladder) dated 11/6/24 documents: Always incontinence of urine. Care plan dated 5/3/22 documents: R10 is incontinent of bladder/bowel. This problem is…

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

Based on observation, interview, and record review, the facility failed to 1.follow their policy on hand washing by not performing hand hygiene when entering the kitchen, 2. failed to follow their policy on use of gloves by not performing hand hygiene prior to putting on gloves and when removed, 3. failed to follow their policy on use of hair restraints by staff entering the kitchen without putting on a hair net, 4. failed to follow their policy on use of wipe cloths by leaving cloths on the food preparation table and not ensuring they are in a sanitation bucket, 5. failed to follow their policy on use of sanitizing buckets by failing to maintain the sanitizing solution at 200 ppm (parts per million) of quaternary solution , 6. failed to follow their policy on use of thermometers by failing to sanitize a thermometer prior to obtaining food temperatures, and 7. failed to follow their policy on use of standardized recipes by not using a recipe during food preparation for lunch. These failures have the potential to affect all 63 residents who receive oral meals from the facility'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 have a five percent (5%) or lower medication error rate. There were nine (3) medication errors out of 30 medication opportunities, resulting in a 10% medication error rate. This applies to 2 residents (R20, R42) of 4 residents observed during medication administration. Findings included: 1. On 12/17/2024 at 9:50 AM Medication observation with V17 (Agency Registered nurse) completed for R20. R20 has a diagnosis of anemia, benign prostatic hyperplasia, elevate prostate antigen and failure to thrive. V17 omitted giving Cyanocobalamin Tablet 1000 MCG and finasteride 5mg 1 tab was missing from the medication cart, medication not given. Per Physician order sheet dated: December 2024 reads: a-Cyanocobalamin Tablet 1000 MCG Give 1 tablet by mouth one time a day scheduled for 9:00AM b- Finasteride Tablet 5MG Give 1 tablet by mouth one time a day scheduled for 9:00AM 2. On 12/17/2024 at 9:36 AM Medication observation with V17 (Agency Registered nurse) completed for R42. R42 has a diagnosis of anemia, nausea, vomiting,…

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 records reviewed the facility failed to follow their policy to ensure that medications were stored safely and securely. This affected one of three residents (R4) reviewed for medication storage. This failure resulted in one resident (R4) accessing the medication cart. The findings include: On 11/2/24 at 1:28PM V8, Registered Nurse (RN), said I worked on 10/20/24, on the night shift. V8 said I received in report from V11, Licensed Practical Nurse (LPN), I think that was her, that R4 got into the medication cart. V8 said I was told the CNA reported seeing R4 in the cart. V8 said R4 told me she was counting her medication in the cart, I was counting my oxy. V8 said V11 and R4 did not tell me how R4 got in the cart. V8 said I did not report to anyone because V11 told me she reported to the Director of Nursing (DON). V8 said R4's room was outside the nurses station. On 11/2/24 at 1:52PM V2, CNA, said R4 was loud and rude and she would go off. V2 said I never saw R4 in pain. V2 said if R4'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 interviews, and record review, the facility failed to honor a residents preference for showering. This affected one of three residents (R4) reviewed for residents rights. Findings Include: Interviewed R4 on 6/29/24 at 10:15AM. R4 stated she's never had a shower and did not know the days of her showers. Surveyor has to give the shower schedule information for R4. R4 shower days are Monday and Thursday Evening shift. R4 stated R4 never knew about the shower chair. R4 requested for shower bed because R4 was using the shower bed at home. The staff never offered the shower chair, so R4 thought there is no shower chair in the facility. R4 stated that staff clean R4 every day, but R4 still wants that water on R4's body. R4 want R4's shower and not just bed bath. R4 stated, (R4)'s been in the facility for 3 weeks now, and has only received bed baths, not shower. R4 was admitted in the facility on 5/23/24, and still a current resident in the facility. R4 has a BIMs score of 15 (Cognitively intact). On 6/21/24 at 9AM, V12 (Administrator) stated that they don't have the shower sheets…

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 keep one resident (R1) free from restraints, in a sample of 7 residents reviewed for restraints. Findings include: R1 is [AGE] years old with the diagnosis not limited to: Dementia, Anxiety Disorder, Muscle wasting and Atrophy, Repeated Falls. R1's Brief Interview for Mental Status score is 9, meaning moderate cognitive impairment. Facility's reportable to state agency with incident date of 12/05/2023 at 7:30 am documents in part: It was reported to administrator and Director of nursing that resident R1 was observed to be restrained to his wheelchair. Resident immediately had the restraint device removed. Resident was assessed with finding of no injury or distress. MD notified. Family notified. Staff member who applied the restraint was identified as V11, C.N.A. Employee was suspended pending investigation. R1 denied distress or harm. V11 was interviewed and stated that she secured the resident to his chair in attempt to prevent him from falling. She…

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 schedule sufficient staff to meet resident care needs in a timely manner for seven shifts of ninety shifts reviewed. This failure has the potential to affect all 56 residents listed on the facility census. Findings include: On 12/5/23 at 3:55 PM R3 said sometimes the staff tell us that there is only one CNA (Certified Nursing Assistant)on duty, so we have to wait a long time to get changed. Then one girl tries to take care of the whole floor, that has happened several times. On 12/5/23 at 4:05 PM R4 said sometimes I have to wait all day to get changed. I'm not going to sugar coat anything. Once a shift is not enough to get changed. I'm incontinent. I have to take Lasix (diuretic) sometimes and that makes me urinate more. When we ask to be changed, sometimes they say, I already changed you. On Monday no one came in and changed us all day. On 3-11pm shift, sometimes there is one person. I have been left unchanged for 20 hours . On 12/7/23 at 10:50 AM R5 said they take a long time to answer the lights if they come at all.…

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

Based on interview and record review, the facility failed to have RN (Registered Nurse) coverage for 8 hours/day 7 days/week for one day, 11/24/23 of thirty days reviewed for nursing coverage. This failure has the potential to affect all 56 residents in the facility. Findings include: The Daily Nursing Schedule was reviewed for thirty days 11/1/23-11/30/23. There was no Registered Nurse coverage for 11/24/23. There was no RN clocked in for 11/24/23. On 12/6/23 at 2:10 PM V2 (Director of Nursing/Scheduler) said we have an RN in the building for at least eight hours every day. I am here every weekday and sometimes I will come in on a weekend day. We have an agency to send an RN if we don't have anybody to pick up a shift. I didn't have an RN on the schedule on 11/24/23. If I came in that day it was just for a few hours. The facility census lists the census as 56 residents at the time of this survey. Policy Registered Nurse Coverage, undated Except when waived under paragraph (e) or (f) of section 483.35 (b) (1)-(3). It is the policy of the facility to provide the services of an RN 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 observation, interview and record review the facility failed to ensure residents who are dependent on staff for toileting received incontinence care. This applies to 4 of 9 residents (R4, R5, R6 and R9) reviewed for activities of daily living in the sample of 9. The findings include: 1. On 11/25/23 at 9:00 AM, R4 was observed laying in bed. R4 said they were short staffed last night, the last time he was changed was at 10:30 PM. R4 said he told the staff he was soiled this morning and the CNA (Certified Nursing Assistant) said she would change him when she gets me up from bed. On 11/25/23 at 9:10 AM, V9 (CNA) said she is R4's CNA today. She has to pass breakfast trays then has to feed residents and is not sure when she can change R4. On 11/25/23 at 10:30 AM, V9 (CNA) provided incontinence care to R4. R4's incontinent brief was heavily saturated with urine. R4's face sheet shows he is a [AGE] year-old male with diagnoses including quadriplegia, hemiplegia affecting his left non-dominant side, muscle…

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 follow their policy to report an injury of unknown origin for one (R1) of three residents reviewed for abuse reporting. The findings include: R1's diagnosis include but are not limited to Hemiplegia Affecting Right Dominant Side, Dementia, Contracture Left Hand, Hypertension, Cognitive Communication Deficit, Adult Failure to Thrive, and Need For Assistance with Personal Care. R1 is severely cognitively impaired. R1 is African American. On 9/27/23 at 9:47AM V11, Certified Nursing Assistant (CNA) said I worked night shift on 9/22/23. V11 said at 11:00PM I saw R1, she was dry and asleep. V11 said at around 12:00PM -12:30PM the nurse did rounds and came and told me R1 was wiggling and wet so I went to change her. V11 said when I pulled the covers I saw it on her hip, before I took off the diaper. V11 said It looked like a burn to me. V11 said it was puffed up, round, white, and around the diaper had blood on the side. V11 said I told the nurse to come look. V11 said in the morning I spoke with the Director of Nursing 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 interviews and record review the facility failed to follow their policy to investigate the cause an injury of unknown injury for one resident (R1) of three residents reviewed for investigation of injury of unknown origin. Findings include: R1's diagnosis include but are not limited to Hemiplegia Affecting Right Dominant Side, Dementia, Contracture Left Hand, Hypertension, Cognitive Communication Deficit, Adult Failure to Thrive, and Need For Assistance with Personal Care. R1 is severely cognitively impaired. R1 is African American. On 9/27/23 at 10:13AM V9, DON, said the clerk spoke to me and said R1's daughter needed the wound nurse. V9 said this call happened around 11:00AM. V9 said the area appeared Saturday morning. V9 said the conclusion is that the it was a skin discoloration, not a wound. V9 said the nurse should have told me about it. V9 said no one mentioned a burn to me, I don't know what it was. V9 said an injury of unknown injury is when something happened that was not witnessed and we don't know what happened. V9 said we would document that on an incident…

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 resident privacy by not knocking on the door and introducing themselves before entering the resident rooms. This failure affected 9 residents (R21, R41, R27, R39, R19, R9, R32, R56, and R13) of 9 residents reviewed for privacy in a total sample of 22. Findings include: On 9-20-23 at 8:43 AM at 9:00 AM during medication administration observation, V5 (Licensed Practical Nurse/LPN) was observed going inside R32 and R56's room twice without knocking on the door, announcing self, or asking permission to come in. At 9:15 AM during medication administration observation, V9 (Registered Nurse/RN) was observed going inside R13's room without knocking on the door, announcing self, or asking permission to come in. Between 11:45 AM - 12:00 PM during medication administration observation, V5 was again observed going inside R9's room without knocking on the door, announcing self, or asking permission to come in. On 9-20-23 at 10:30 AM, during Resident Council Meeting, R21, R41, R27, R39, and R19 made concerns 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 observation, interview and record review, the facility failed to maintain infection control practices for the medication refrigerator for one of one medication rooms observed for medication storage. The facility failed to date and discard inhalers per manufacturer's recommendation for one of two medication carts affecting three residents (R24, R32, R57) in a sample of 22. The facility also failed to have a system to account for the receipt of all controlled medications for two of two medication carts (First floor Team 1 and Team 2 medication carts) observed for medication storage affecting all 11 residents receiving controlled medications on both carts. Findings include: 1. On 09/19/2023 at 10:36AM during observation with V8 (Agency Registered Nurse/RN), second floor medication room refrigerator was observed with one strawberry yogurt and an open bag of milk chocolate candies. On 09/20/2023 at 9:12AM during observation with V5 (Licensed Practical Nurse/LPN), Team 1 medication cart was observed with the following: 1. R32's opened budesonide-formoterol fumarate 160/4.5…

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

Based on observation, interview and record review, the facility failed to maintain infection control practices for the medication refrigerator for one of one medication rooms observed for medication storage. The facility failed to date and discard inhalers per manufacturer's recommendation for one of two medication carts affecting three residents (R24, R32, R57) in a sample of 22. The facility also failed to have a system to account for the receipt of all controlled medications for two of two medication carts (First floor Team 1 and Team 2 medication carts) observed for medication storage affecting all 11 residents receiving controlled medications on both carts. Findings include: 1. On 09/19/2023 at 10:36AM during observation with V8 (Agency Registered Nurse/RN), second floor medication room refrigerator was observed with one strawberry yogurt and an open bag of milk chocolate candies. On 09/20/2023 at 9:12AM during observation with V5 (Licensed Practical Nurse/LPN), Team 1 medication cart was observed with the following: 1. R32's opened budesonide-formoterol fumarate 160/4.5…

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 recipe for pureed bread for five residents (R4, R37, R40, R57, and R58) of five residents reviewed for pureed diets in the sample of 22. Findings include: On 09/20/23 at 11:10 AM V33 (Cook) prepared pureed bread by putting six slices of white bread in the food processor. She then added approximately six ounces of water and processed the mixture. The pureed food was covered with foil wrap and left on the table. On 9/20/23 at 11:27 AM V32, (Dietary Director) was asked why the water was used for the pureed bread. She said we don't always order the bread mix. The recipe calls for water. We usually use the ends of the bread that would be thrown away. On 9/20/23 at 11:30 AM V33 added the pureed bread to the steam table. On 9/20/23 at 11:50 AM the temperature of the pureed bread was 197 degrees F measured by V2 (DON). Recipe: undated Scratch Puree Bread: Be sure to use the seedless bread. Add 1 slice of bread to the food processor with 2 Tbsp (tablespoons) of milk and blend to a smooth consistency. If 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 implement appropriate transmission-based precautions and ensure nebulizer and C-pap mask were properly stored in plastic bag and left open to air. This failure affects six of six residents (R10, R16, R29, R37, R47, R48) observed for infection control in a sample of 22. Findings include: 1. On 09/19/2023 between 10:45AM to 11:20AM V29 (Certified Nursing Assistant/CNA) was observed going outside of an isolation room twice to get linens from the linen cart without any gown on and going back inside without putting a gown on. A sign outside the door reads Enhanced Barrier Precautions. On 09/19/2023 at 11:21AM, V29 said she didn't think she has to wear a gown to do incontinence care and change linens for residents in the room (R37, R47, R48 and R10). V29 then looked at the door and read the sign that reads Enhanced Barrier Precautions. V29 then stated that she was sorry, and she should have worn a gown before going inside the room. On 09/19/2023 at 11:30AM, V2 (Director of Nursing) said that all staff who will do…

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

Based on observation, interview and record review, the facility failed to provide services to maintain range of motion for three of three residents (R37, R39, R47) reviewed for range of motion in a sample of 22. Findings include: On 09/19/2023 at 11:20AM during observation with V2 (Director of Nursing), R37 was observed with the fingers on her left hand pressing against her palm without a hand splint or hand roll on, and the resident was unable to open her hands by herself. At 11:15AM, R47 was also noted with the fingers on the left hand pressing against her palm without a hand splint or hand roll on, and the resident was unable to open her hands by herself. On 09/19/2023 at 11:20AM, V2 said that she will have V7 (Restorative Nurse) come and see R37 and R47. On 09/21/2023 at 2:39PM, V7 said that R37 should have her left-hand splint on. V7 also stated that R47 should have a splint on her left hand and would have been started on it if R47 was assessed during the significant change assessment on 08/13/2023. V7 said that splints prevent further contractures and it protects the palm from…

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, interviews and record review, the facility failed to follow their oxygen administration policy and failed to follow the orders for oxygen administration. This deficient practice affects one resident (R43) of three residents reviewed for oxygen administration in a total sample of 22 residents. Findings Include: On 9/19/23 at 10:45 AM, observed R43 in bed and using CPAP (Continuous Positive Airway Pressure) machine connected to an oxygen concentrator. Oxygen concentrator observed to be at 7L (Liters) per minute. On 9/19/23 at 11:00 AM, confirmed with V5 (LPN) that the oxygen concentrator is set at 7L. V5 stated that R43 is supposed to be on 2-4L of oxygen. On 9/20/23 at 8:55AM, observed R43 sitting in bed, CPAP not in use. R43 awake and oxygen concentrator is set to 3L with bottle humidifier. R43 stated that usually a humidifier is used, but does not know why there was nothing connected yesterday. R43 thinks she is supposed to be on 2-3L of oxygen as needed. R43's POS (Physician Order Sheet) reviewed oxygen order with start date of 9/19/23 Oxygen at 3 liters per…

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 residents are free from significant medication error for one of four residents (R9) observed for medication administration in a sample of 22. Findings include: On 09/20/2023 at 12:00PM during medication administration observation, V5 (Licensed Practical Nurse/LPN) was observed preparing insulin lispro kwik pen for R9. V5 was observed priming the insulin pen without a needle and without holding the pen upright. V5 then proceeded to put on the needle, prepare the dose and administered the insulin to R9. On 09/20/2023 at 12:05PM, V5 said that she usually primes the insulin pen without the needle on and she has not been told otherwise. On 09/21/2023 at 3:14PM, V2 (DON) stated that there should be a needle on the insulin pens when primed because if not, it might give the wrong dose to the resident. On 09/21/20203 at 3:25PM, V34 (Pharmacy Consultant) stated that insulin pens should be primed with a new needle in place. V34 also said that if the needle is not present when priming, the right dose might not be…

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

Based on interview and record review the facility failed to complete an investigation for an allegation of resident-to-resident abuse for two residents (R9, R51) of four residents reviewed for abuse in the sample of 22. Findings include: A report was sent to the Illinois Department of Public Health on 7/7/23 alleging that R9 made physical contact with R51. In a visit 9/19/23-9/22/23 the facility did not provide any documentation of an investigation of the incident. There are no interviews of potential witnesses. There is no documentation in the progress notes or care plans of R9 and R51. On 9/19/23 at 11:14 AM R51 said there was a little incident with (R9) a few weeks ago. I was watching a TV program in the big room across the hall with a friend (R52). I went to get my jacket. When I went back into the room the TV had been changed. I asked (R52) if he changed the TV since we were watching a program. He said that (R9) had changed the channel without asking. I picked up the remote off the table and changed it back. As I walked (R9) was yelling and tried to hit me and missed. Then she…

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 records review the facility failed to follow it protocol for hot weather emergency, by failing to document areas of the facility affected by insufficient cooling as denoted by the emergency plan. Failure to document the ambient temperatures in the resident care area and common areas put the residents and workers at risk for heat related injuries. This failure could have affected all 60 residents, on census by exposing them to heat related injury or illness. Findings include: Surveyor arrived on sites at 10:35AM on 08/25/23 and found the facility to be comfortable at that time, there were fans in operation throughout the first floor, second floor and common areas as well as administrative areas. I met with V1, V2 and V3 to inform of survey for inadequate cooling, V2 was able to explain that the facilities cooling system is antiquated, but still functions. However, on extremely hot days the chiller does not provide enough cold water to cool the pipes and provide cool air. V2 went on to explain that when it gets too hot, the facility will provide…

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 menus are followed and failed to identify the residents meal preferences resulting in meals being served that were insuffient for meeting the resident's needs. This failure applied to four (R17, R48, R73, and R126) of four residents reviewed for nutrition and has the potential to affect all 75 residents currently in the facility. Findings include: On 08/29/22 from 09:51 AM - 10:10 AM Observed breakfast menu for today to include choice of hot or cold cereal, scrambled eggs with cheese, and toast. Observed all residents breakfast meal prepared without including eggs and cheese. On 08/29/22 at 12:35 PM R126 stated he doesn't like butter or creamy items and his breakfast often has butter on it. On 08/30/22 at 08:40 AM R48 stated normally there is hard boiled served with breakfast but was not today. R48 stated she was looking forward to the eggs. R73 reported he had one piece of toast and corn flakes for breakfast and it was not enough. R73 stated this happens four days out of 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 observations and interviews, the facility failed to follow their policy and procedures for preparing food under sanitary conditions by not using PPE (Personal Protective Equipment properly, not wearing required hair covering while working in the kitchen, not performing hand hygiene when necessary, not ensuring sanitizer solution was prepared properly, not ensuring the kitchen area is in good repair and free from contamination, not ensuring food equipment was cleaned and stored properly, and not ensuring the ice machine was thoroughly clean when in use. Findings include: On 08/29/22 from 09:51 AM - 10:10 AM Observed V20 (Dietary Aide) working in the kitchen in the dish area without a hairnet on. V20 stated he was not wearing a hairnet because he was hot. Observed V21 (Dietary Aide) washing dishes with her mask worn underneath her chin. V21 stated she was wearing her mask underneath her chin because she was hot. V22 (Cook) stated V19 (Dietary Manager) was not there and comes in and helps out sometimes but is in and out. V22 stated the dietary manager was supposed to start on…

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

Based on observation, interview, and record review, the facility failed to properly prevent the spread of infections by staff not wearing proper personal protective equipment (PPE's), failing to ensure that staff were properly notified of residents on isolation precautions, failing to ensure that blood pressure equipment was properly sanitized in between residents, and they failed to ensure that urine collection containers were properly cleaned. This failure has the potential to affect all 75 residents currently residing in the facility. Findings include: On 08/29/22 at 10:30 AM, R73's room was observed to have two urine containers on resident's side table about a quarter full of urine. On 08/30/22 at 11:40 AM, noted R73 to still have two urine containers about a quarter full of urine, observed to be unchanged. On 08/29/22 at 10:45 AM, noted R70 to have isolation bin outside of room. Asked V7 (Licensed Nurse Practitioner) why R70 was on isolation. V7 said She has something in her urine, just put a gown on. V7 could not verbally tell this surveyor what kind of isolation precautions…

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 and interview, the facility failed to maintain a safe, clean, and homelike environment by failing to keep furniture, equipment, and room condition functional and in good repair, by failing to keep rooms in a clean, sanitary condition, and by failing to store resident's belongings in a dresser/closet. The failures applied to three of three (R35, R42, and R73) residents reviewed for environment. Findings include: On 08/29/22 at 10:30 AM, R35's room was observed to have a garbage bag on side table with various belongings including clothing and reading book. Observed resident's dresser to be empty. Also observed roommate, R10 to have garbage bag of belongings such as clothes, tissue paper, clean incontinence products, and shoes. Spoke with V6 (Environmental Service Director) said that the bags on the floor are most likely due to room changes and have yet to be unpacked. Observed V6 to turn dresser in room [ROOM NUMBER] around. Noted front of dresser to be inaccessible and front facing towards…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their medication storage policy for eye drops and expired or discontinued medications. This failure applies to four (R34, R52, R60, R77) of four resident's medications reviewed in one medication storage room, and in two of four medication carts during the medication storage and labeling facility task. Findings include: On 08/30/22 at 7:08 AM, observed treatment cart next to room [ROOM NUMBER] on the second floor was unlocked. Approached V7 (Licensed Practical Nurse) who was walking on the unit to inquire on what was stored within the cart. V7 opened the drawers and surveyor observed two pairs of scissors in the first/top drawer, multiple wound care creams and ointments supplied by facility's pharmacy in the second drawer, two bottles of Dakin's (wound cleanser with bleach) and two bottles of hydrogen peroxide all within the third drawer. When asked if the cart should be locked, V7 (Licensed Practical Nurse) said yes it should be.…

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 notices of resident transfer to the resident's representative and to the Office of the State Long-Term Care Ombudsman after a resident was emergently transferred to the hospital. This failure applied to one (R7) of one resident reviewed for discharge and transfer. Findings include: R7 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include COPD, unspecified asthma, and unspecified osteoarthritis. R7 was reviewed as a closed record and is not currently in the facility. Review of medical record documents that resident went to appointment on 8/19/22 and the physician's office made the decision to admit the resident to the hospital. Nursing progress note dated 8/19/2022 11:50, reads: Note Text: This nurse received A call from (local hospital) that resident will be getting admitted due to (Hypotension). Resident family was made aware as well as DON. Staff will continue to monitor. Nursing progress note…

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 a resident's representative with a notice of bed-hold policy after a resident was emergently transferred to the hospital. This failure applied to one (R7) of one resident reviewed for discharge and transfer. Findings include: R7 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include COPD, unspecified asthma, and unspecified osteoarthritis. R7 was reviewed as a closed record and is not currently in the facility. Review of medical record documents that resident went to appointment on 8/19/22 and the physician's office made the decision to admit the resident to the hospital. Nursing progress note dated 8/19/2022 11:50, reads: Note Text: This nurse received A call from (local hospital) that resident will be getting admitted due to (Hypotension). Resident family was made aware as well as DON. Staff will continue to monitor. Nursing progress note dated 8/19/2022 07:45, reads: Note Text: THIS WRITER 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 develop and implement a resident centered baseline care plan for a newly admitted resident within 48 hours of admission in order to meet the resident's individualized needs and to determine specified care to be provided. This failure applied to one (R78) of one resident reviewed for baseline care plans. Findings include: R78 is a [AGE] year old male who was admitted to the facility on [DATE] and expired in the facility on 6/19/22. R78 was reviewed as a closed record. R78 had diagnoses that included: sepsis due to pseudomonas, unspecified dementia without behavioral disturbance, schizophrenia, and dysphagia unspecified. Nursing progress note dated 6/19/2022 15:51 reads: Note Text: At 8 am resident is sleeping in bed with no signs of distress noted skin warm dry to touch with no complaints of pain at this time. Staff made an attempt to feed the resident but resident refused his breakfast after 3 trials. G tube patent and intake infusing per…

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 prepare a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications; the facility also failed to convey the discharge summary to the receiving facility at the time of discharge. This failure affected one (R76) of one resident reviewed for transfer and discharge. Findings include: R76 is a [AGE] year old female initially admitted to the facility on [DATE] with diagnoses including but not limited to: chronic obstruction pulmonary disease (COPD), convulsions, polyosteoarthritis, chronic ischemic heart disease, osteoporosis, hyperlipidemia, gastro-esophageal reflux disease, depressive disorder, psychosis, anxiety disorder, panic disorder, hypertension, unsteadiness on feet, anemia, dysphagia. R76's medical records reviewed during the course of this survey and did not contain a complete discharge summary including a…

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

Based on observation, interview, and record review, the facility failed to follow physician medication orders by not administering medication by the correct route and by failing to ensure that pain medication was available and in stock for resident to receive according to physician orders. This failure applied to two (R33 and R64) of two residents reviewed during medication administration. Findings include: On 08/30/22 at 06:48 AM, V3 (Licensed Practical Nurse) said R64 prefers to take his medications by mouth even though his order says to administer through the gastrostomy tube (g-tube). At 06:52 AM, observed V3 (Licensed Practical Nurse) administer to R64: Gabapentin 300mg one capsule and Omeprazole 20mg one tablet all by mouth. Reviewed R64's active physician's orders that showed orders for Gabapentin Tablet 300mg one capsule via g-tube three times daily and Omeprazole Suspension 2mg/ml give 10ml via g-tube two times daily. No progress note found for R33 indicating the facility requested to change the route of administration. On 08/30/22 at 08:59 AM, R33 said he had not 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.

Based on observations and interviews the facility failed to follow their protocol for ensuring timely incontinence care for a resident who had been sitting with a loose stool for an extended period of time resulting in the resident experiencing discomfort. This failure applied to one (R49) of one resident reviewed for incontinence care. Findings include: On 08/30/22 at 09:48 AM R49 stated she had been sitting in loose bowels for 20 minutes. R49 stated she informed her Certified Nursing Assistant and was told she'll return. Observed R49 with an odor of feces. R49 stated she had pressed her call light twice already. R49 stated the CNA advised she'd be back and never returned. Observed R49 moaning in discomfort and leaning to her right side. R49 stated she needed to remain in this position because she was too uncomfortable from the loose stools on her bottom. On 08/30/22 at 10:01 AM V30 (Certified Nursing Assistant) stated R49 pulled the call light about ten minutes ago and reported she had a bowel movement. V30 stated she informed R49 she would be back after assisting another…

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

Based on observation, interview, and record review, the facility failed to administer medications as ordered to maintain a medication error rate of less than 5% (percent). There were 25 medication opportunities with four errors resulting in a 16% (percent) medication error rate. This failure applied to three (R3, R33, R64) of six residents observed during the medication administration task. Findings include: On 08/30/22 at 06:48 AM, V3 (Licensed Practical Nurse) said R64 prefers to take his medications by mouth even though his order says to administer through the gastrostomy tube (g-tube). At 06:52 AM, observed V3 (Licensed Practical Nurse) administer to R64: Gabapentin 300mg one capsule and Omeprazole 20mg one tablet all by mouth. Reviewed R64's active physician's orders that showed orders for Gabapentin Tablet 300mg one capsule via g-tube three times daily and Omeprazole Suspension 2mg/ml give 10ml via g-tube two times daily. No progress note found for R33 indicating the facility requested to change the route of administration. On 08/30/22 at 08:34 AM, observed V4 (Registered…

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.