Oak Park Oasis

Based on interview, and record review the failed to ensure stop dates for residents with prn (as needed) psychotropic medications were in place for 2 of 3 residents (R1, R3) reviewed for psychotropic medications in the sample 4. The findings: R1's Physician Order Sheets dated May 2025 shows orders including Haloperidol 5 mg (milligrams) every 6 hours as needed for behavior disturbance and Lorazepam 1 mg every 6 hours as needed for behaviors (both order date of 3/4/25). R3's Physician Order Sheets dated May 2025 shows orders including Lorazepam Injection 0.5 ml every 8 hours as needed for agitation (order date 4/29/25). On 5/16/25 at 12:10 PM, V3 (Assistant Director of Nursing-ADON) said psychotropics prn medications should have a stop date of 14 days. The facility's Psychotropic Drug Therapy undated policy states, Psychotropic drug therapy will be used when necessary to treat a specific condition .PRN (as needed) psychoactive medications will be ordered with a time limit of 14 days. After that time, Physicians may re-evaluate and reroder at 14 day intervals. There must 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 a clean, comfortable, and homelike environment for 9 (R3, R4, R5, R6, R7, R8, R10, R11, and R12) of 12 residents reviewed for environment. The findings include: On 3/22/25 at 10:04AM R8's room has four tiles missing from the main room floor. R8 was observed in the bed, opened her eyes but did not respond to the surveyor's question. On 3/22/25 at 10:06AM R3's room was observed. The top veneer finish lifts off to expose plywood/particle board underneath. A round hole was [NAME] key lock fell out. 2 window curtains in the room, one is hung and can slide to open and close, but second curtain is partially hung. Curtain hooks/clips observed on the window ledge. Trim boards look dirty with discolored, dark black/brown grime. Black, dark, spotted discoloration along floor trim and floor that is along wall. R3 said her window curtains have been like that for a couple weeks. R3 said she is unable to open or close the windows, they stay like…

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 notify a physician that a resident was not being administered a steroid topical ointment and an immunosupressive medication as ordered and missed 15 doses of the steroid topical ointment and 14 doses of the immunosupressive medication for one out of three residents (R1) reviewed for physician notification in a total sample of three. Findings Include: R1 is a [AGE] year old with the following diagnosis: rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic ulcer of skin. On 2/26/25 at 11:30AM, R1 was only available by phone for interview due to being hospitalized at the time of the investigation. R1 stated R1 does not the get medication for R1's autoimmune disease. R1 was unable to remember the name of the medication but knew it started with an M. R1 reported the medication is supposed to be taken twice a day (once in the morning and once around dinner time) but it is only given usually once a day or not at all. R1 was unable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer a topical steroid ointment and an immunosupressive medication as ordered causing the resident to miss 15 doses of the topical steroid ointment and 14 doses of the immunosupressive medication over a two month period for one resident (R1) out of three reviewed for medication administration in a total sample of three. Findings Include: R1 is a [AGE] year old with the following diagnosis: rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic ulcer of skin. On 2/26/25 at 11:30AM, R1 was only available by phone for interview due to being hospitalized at the time of the investigation. R1 stated R1 does not the get medication for R1's autoimmune disease. R1 was unable to remember the name of the medication but knew it started with an M. R1 reported the medication is supposed to be taken twice a day (once in the morning and once around dinner time) but it is only given usually once a day or not at all. R1 was unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy by not preventing a resident to resident physical assault. This affected two of three residents (R1, R2) both reviewed for physical abuse. This failure resulted in R1 being punched in the face and being transferred to the local hospital for evaluation Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of heart failure, dementia, schizophrenia, depression and auditory hallucinations. R1's brief interview for mental status score dated 11/8/24 documents score 10/15 which indicates moderate cognitive impairment. On 12/31/24 at 2:22PM, R1 who was alert and oriented was asked if he recalls the incident with his roommate. R1 said yes. R1 said there was something wrong with the toilet in his room that it wasn't flushing. R1 said R2 punched him in the face two times. R1 was unsure where it happened or why. R1 unable to recall if he went into bathroom with R2. R1 does not recall any injury or any other details.…

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 develop a plan of care for a resident with a history of violent behavior. This affected one of three residents (R2) reviewed for care plans. Findings include: R2 was admitted on [DATE] with a diagnosis of Huntington's disease, violent behavior, brief psychotic disorder and schizoaffective disorder. R2's brief interview for mental status score dated 12/2/24 documents score 14/15 which indicates cognitively intact. R2's progress note dated 10/11/24 documents: altercation with roommate. Staff attempting to separate, both residents punching at each other but hitting staff. Spitting at each other. R2 held other resident by the neck. R2 was sent to the hospital via petition. R2's petition dated 10/11/24 documents: R2 physically aggressive towards roommate, fighting and throwing punches to the roommate but punches landed on staff nurse, held his roommate's neck. R2's hospital record dated 10/11/24 documents: R2 admitted for aggressive behaviors of choking…

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 and injury of unknown origin policy by not initiating and completing a thorough investigation of an injury of unknown origin reported to the facility by a resident's family member. This failure applied to one (R1) of three residents reviewed for injury of unknown origin investigations. Findings include: R1 is [AGE] years of age. Current diagnoses include but are not limited to: Cerebrovascular Disease and Dementia Behavioral Disturbance. R1's MDS Minimum Data Set (Comprehensive Assessment) section C cognitive status dated 10/4/2024 documents a staff assessment indicating R1 being moderately impaired- decisions poor; cues/supervision required. R1 was admitted to the facility on [DATE] for respite care and was discharged home with family on 10/4/24. On 11/13/24 at 11:08 AM, interview with V4 LPN Licensed Practical Nurse regarding R1's bruising concern. V4 said, The lady family member said it was something on her arm, it was a bruise…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement enhanced barrier precaution protocol. The facility failed to observe appropriate infection control protocol in handling soiled linens. The facility failed to have measures in place to prevent the growth of legionella and other opportunistic waterborne pathogen in building water system. The facility failed to clean, disinfect medical equipment, and perform hand hygiene during Intravenous medication administration. These deficiencies have the possibility to affect all residents in the facility. Findings include: On 10/22/24 at 6:18AM, Observed soiled linens in a green plastic bag on the floor in the hallway outside by room [ROOM NUMBER] and two bags by the therapy room. V14 LPN (Licensed Practical Nurse) said that it should not be placed on the floor, it should be brought to the soiled linen chute. On 10/22/24 at 6:31AM, V15 CNA (Certified Nurse Assistant) said that soiled linens in green plastic bag should not be placed on 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 privacy and dignity to residents. This deficiency affects three (R65, R112 and R372) of three residents in a sample of 24 reviewed for residents right. Findings include: On 10/22/24 at 9:10AM, R372 observed in bed with Foley catheter bag hanging on left side of bed visible when entering the room with no privacy bag covering. On 10/22/24 at 9:20AM, R112 observed sitting in bed with Foley catheter bag on left side of bed sitting on floor and no privacy bag covering. On 10/23/24 at 1:23 PM, V14 (Licensed Practical Nurse) did not provide privacy during intravenous medication administration for R112, V14 did not close room door and did not pull privacy curtain. On 10/23/24 at 1:28PM, R64 observed in bed with no privacy curtain available. On 10/22/24 at 9:25AM, V14 (Licensed Practical Nurse) verified that R372 did not have a Foley catheter privacy covering bag, V14 said that the Foley catheter bag should have a privacy bag covering in place. On 10/22/24 at 9:28AM, V14 verified with surveyor that R112 Foley…

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 care plan was updated to reduce the risk of falls for one of three residents (R77) reviewed for falls in a sample of 24. Findings include: On 10/22/2024 at 10:30am R77 was observed in a chair next to the nurse's station. On 10/22/2024 at 10:33am V24 (Licensed Practical Nurse-LPN) said she is a high fall risk I'm waiting for activity to take her to the dining area. On 10/24/2024 at 11:00am V28 (Minimum Data Set-MDS Consultant), observed with the surveyor that R77 had a fall on 5/25/2024 sustaining a hematoma and no care plan update, R77 had a fall on 9/10/2024 no injury and no care plan update. On 10/24/2024 at 11:05am V3 (Director of Nursing-DON) said the MDS coordinator should update the care plan after every fall she resigned last week. A fall incident report dated 5/25/2024 indicated that R77 had an unobserved fall and sustained a hematoma to forehead and was transferred to the local hospital, no care plan update. On 9/10/2024 R77 had a unobserved fall no injury and no care plan update. An order…

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 nail care to dependent resident. This deficiency affects one (R110) of three residents in the sample of 24 reviewed for ADL (Activity of Daily Living) care. Findings include: On 10/22/24 at 8:50AM, Observed R110's bilateral fingernails with long and dirty. There are with black matter inside the fingernails. On 10/23/24 at 9:50AM, Observed R110 still with long and dirty fingernails. Showed observation to V23 LPN (Licensed Practical Nurse). V23 said that the CNA (Certified Nurse Assistant) should provide nail care- clean and trim R110's fingernails when providing personal hygiene or bathing/shower. They should check resident fingernails weekly. On 10/23/24 at 1:38PM, Informed V3 Director of Nursing (DON) of above observation. V3 said that the CNA should check for resident's nails when providing ADLs (Activity of Daily Living) and provide nail care as needed. R110 is admitted on [DATE] with diagnosis listed in part but not limited 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 follow physician order in application for right hand splint to resident. This deficiency affects one (R110) of three residents in the sample of 24 reviewed for Restorative Nursing Program. Findings include: On 10/22/24 at 8:56AM, Rounds made with V13 Restorative Nurse to R110. Observed R110 lying on bed with tracheostomy tube connected to oxygen concentrator. He does not wear right hand splint. R110 is admitted on [DATE] with diagnosis listed in part but not limited to Acute respiratory failure with hypoxia, Tracheostomy status, Reduced mobility, Severe protein calorie malnutrition. Active physician order sheet indicates: Primary care physician confirmed order for right hand splint dated 7/30/24. Comprehensive care plan indicates that he has ADL self-care performance deficit related to malnutrition, respiratory failure, dysphagia, epilepsy, tracheostomy tube, gastrostomy tube, resident requires substantial to total assist with ADLs.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to have an order for tracheotomy tube size and oxygen usage in resident chart. The facility failed to ensure to have an accessible spare tracheostomy tube kit in case of emergency /accidental decannulation. The facility failed to ensure oxygen tubing is changed and dated weekly and as needed. This deficiency affects two (R110 and R372) of three residents in the sample of 24 reviewed for Respiratory Care. Findings include: On 10/22/24 at 8:50AM, Rounds made with V13 Restorative Nurse to R110. Observed R110 lying in bed with tracheostomy tube connected to oxygen concentrator at 2.5LPM.(liter per minute) Oxygen tubing is not dated. V13 searched the bedside drawer for spare tracheostomy tube set or obturator but unable to locate. V13 said that there should be a spare tracheostomy tube at bedside for in case of emergency. On 10/22/24 at 11:30AM, Informed V3 DON (Director of Nursing) of above observation made with R110 having no spare tracheostomy…

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

Based on observation, interview, and record review the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs. This deficiency affects one (R112) of one resident reviewed for intravenous medication administration in a sample of 24 residents. Findings include: On 10/23/24 at 1:23 PM, observation made with V14 (Licensed Practical Nurse) for intravenous medication administration for R112, V14 did not perform hand hygiene between change of gloves and before exiting room. V14 did not provide privacy during intravenous medication administration, V14 did not close room door and did not pull privacy curtain. On 10/23/24 at 1:30PM, V14 said that he should have performed hand hygiene between glove change and provided privacy to the resident when administering medication. On 10/23/24 at 1:52PM, V3 (Director of Nursing) said that LPN (Licensed Practical Nurse) can administer intravenous medications. Also said that V14 should have performed hand hygiene before and after glove usage and before exiting room. V3 said that…

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 completion of infection verification tool upon initiation of antibiotic using the McGeer's criteria. This deficiency affects one (R108) of three residents in the sample of 24 reviewed for Antibiotic Stewardship Program. Findings include: On 10/23/24 at 12:02PM, V3 Director of Nursing (DON) and V7 Infection Preventionist said that R108 is currently on Cephalexin 500mg(miligram) Two tablets orally twice a day for Cellulitis. Both said that infection verification assessment was not done upon initiation of antibiotic using McGeer's criteria. V3 said that the floor nurse is the one responsible for completing the Mc Geer's criteria/Antibiotic assessment when the nurse received antibiotic order from the physician. Then V7 will review the assessment/criteria is being met for antibiotic usage. On 10/24/24 at 9:50AM, Observed R108 sitting on bed with right lower leg bandage. He is alert and oriented, able to verbalize needs to staff. R108 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident from a potential sexual abuse by not monitoring a resident with a history of wandering from going into other resident rooms. This failure affected one (R1) of three residents reviewed for abuse. Findings include: R1 is a [AGE] year-old female who was admitted to the facility 07/13/2021 with diagnosis history of Dementia with behavioral disturbance, Psychosis, Vitamin D Deficiency, Gastroesophageal reflux disease, Dysphasia, Bipolar, and history of falling. On the (MDS) Minimal data Set assessment of 06/24/24 section C the BIMS (Brief Interviewed Mental status) score was 07/15and on MDS of 06/25/24 section GG R1 requires walking supervision or touching assistance. R2 is a [AGE] year-old male who was admitted to the facility on [DATE] and discharged [DATE] after an allegation of sexual abuse towards R1. R2 has a diagnoses history of Dementia, Hypertensive, Encephalopathy, Cerebral atrophy, Right Inguinal Hernia, and Anemia. On 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 interviews and record reviews the facility failed to follow their policy and procedure for Involuntary Discharge by not demonstrating that the safety of individuals in the facility was endangered due to the clinical or behavioral status of a resident who was not permitted to return to the facility after hospital transfer and by not ensuring the required documentation for transfer or discharge was included in the resident's medical record. This failure applies to one (R2) of three residents reviewed for involuntary discharge. Findings include: R2 is a [AGE] year-old male with a diagnoses history of Vascular Dementia without Behavioral Disturbance, Depression, Cognitive Communication Deficit, Degenerative Disease of the Nervous System, Seizures, Hepatitis C, Dysphagia, and Gout who was admitted to the facility 10/26/2022. R2's progress note dated 9/16/2024 at 6:20 PM documents he was transferred to the Hospital per physician orders for a psychological evaluation around 6 pm; progress note at 11:14 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision for a resident with dementia and a history of wandering by not ensuring that the resident was not wandering into resident rooms. This failure affected one (R1) of three residents reviewed for supervision. Findings include: R1 is a [AGE] year-old female who was admitted to the facility 07/13/2021 with diagnosis history of Dementia with behavioral disturbance, Psychosis, Vitamin D Deficiency, Gastroesophageal reflux disease, Dysphasia, Bipolar, and history of falling. R2 is a [AGE] year-old male who was admitted to the facility on [DATE] and discharged [DATE] after an allegation of sexual abuse towards R1. R2 has a diagnoses history of Dementia, Hypertensive, Encephalopathy, Cerebral atrophy, Right Inguinal Hernia, and Anemia. On 09/30/24 at 11:19 AM R3 said R1 has a habit of wandering in and out of rooms and did so just a couple of days ago. R3 said on 09/16/24 he was in his room when R1 came in and sat down on R2's bed. 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 prevent a verbal argument from escalating to a resident to resident physical assault. This affected two of three residents (R1, R2) reviewed for resident to resident abuse in the sample of 8. The findings include: R1 and R2 were discharged to the local hospital on 5/22/24 and have not returned to the facility. R1's electronic face sheet printed on 5/26/24 showed R1 has diagnoses including but not limited to dementia without behaviors, history of transient ischemic attack, depression, and heart disease. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment, delusions, and wandering behaviors. R1's care plan dated 5/14/24 showed, Risk for increasing confusion related to diagnosis of dementia . R1's nursing progress notes dated 5/21/24 showed, Resident observed laying on the floor in the hallway. Resident stated, 'She pushed me'. Writer and another staff member assisted resident off the floor and walker her to her room. Full…

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 dependent resident has clean and trimmed fingernails. This deficiency affects one (R49) of three residents in the sample of 23 reviewed for Activity of Daily Living (ADL) care. Findings include: On 12/19/23 at 11:20AM, while V30 (Certified Nursing Assistant/CNA) and V33 (CNA) were providing morning care to R49, the resident was observed with long dirty fingernails on both hands. R49 has contractures on his right hand and the fingernails were pressing on his palm. Informed the CNAs of observation made. Both said that they will inform V12 (Licensed Practical Nurse/LPN). On 12/19/23 at 12:10PM, Informed V12 (LPN) of observation made. V12 said that CNAs and nurses are responsible for cleaning and trimming resident's fingernails as needed. Usually, the restorative aide is the one responsible for it. On 12/20/23 at 10:30AM, informed V3 (Director of Nursing) of above observation. V3 said that the staff, nurses and CNAs, are responsible…

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 identify, assess/monitor, and report the presence of a stage 2 pressure ulcer, and failed to notify the physician for appropriate treatment. The facility also failed to implement pressure ulcer prevention interventions. This failure affects two (R49 and R80) of three residents in the sample of 23 reviewed for Pressure ulcer Prevention Management. Findings include: 1.) On 12/19/23 at 1:03PM, observed R80 lying in bed with oxygen via nasal cannula. She is nonresponsive to verbal stimuli. She needs total care with Activity of Daily Living. She is on a low air loss (LAL)mattress. Surveyor asked V15 (Licensed Practical Nurse/LPN) if R80 has skin impairment. V15 said that he is not aware and will ask V5 (Wound Care Nurse/WCN). Observed that R80 wears a disposable adult brief, with cloth pad and flat sheet over the LAL mattress. On 12/20/23 at 12:57PM, V15 (LPN) said that he spoke with V5 (WCN) and was informed that R80 has no skin impairment, her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to apply a resident's splint/brace as ordered by the physician and as indicated in the resident's restorative assessment and care plan to prevent further contractures. This deficiency affects two (R49 and R80) of three residents in the sample of 23 reviewed Limited Range of Motion. Findings include: 1.) On 12/19/23 at 11:00AM, Observed R49 lying in bed with flexion contractures of the right arm/hand. R49 does not have a splint or brace on his right arm/hand contractures. V30 (Certified Nursing Assistant/CNA) said that she has been taking care of R49, but she has not seen him with a splint or brace to his right arm/hand contractures. V30 CNA does not know if R49 has a splint or brace. On 12/19/23 at 12:10PM, Surveyor informed V12 (Licensed Practical Nurse/LPN) of above observation. V12 said that V32 (Restorative aide) is responsible for applying the splint /braces to residents on the 2nd floor. On 12/19/23 at 1:30PM, V2 (Assistant…

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 obtain physician order for indwelling catheter, the medical indication for usage and the care of the catheter. This deficiency affects one (R80) of three residents in the sample of 23 reviewed for Indwelling catheter management. Findings include: On 12/19/23 at 1:03PM, Observed R80 lying in bed with oxygen via nasal cannula. She is non-responsive to verbal stimuli. She needs total care with ADLs (Activities of Daily Living). She has an indwelling catheter draining to dark yellow, orange urine connected to the drainage bag. On 12/21/23 at 11:20AM, V15 (Licensed Practical Nurse/LPN) said that the resident has an indwelling catheter and should have a physician's order and its clinical indication. Surveyor informed V15 that R80 does not have an order for an indwelling catheter size and type, clinical indication and the care of catheter. V15 said that the admitting nurse should've gotten the order when R80 was re-admitted on [DATE] from 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 follow the Registered Dietician's recommendations and failed to notify the Physician for approval of the recommendations for 1 of 4 residents (R53) reviewed for nutrition in a sample of 23. Findings include: On 12/20/2023 at 1:00pm R53 was asked why he was losing weight, R53 said I cannot chew well, my teeth are bad. The resident exposed his teeth to the writer, which are decayed and missing in places. On 12/21/2023 at 10:00am V5(Wound care Nurse) was asked why did R53 not have a weight on 12/14/2023. V5 said I thought I carried that out, there should be a weight for 12/14/2023. On 12/21/2023 at 10:15am V3 (Director of Nursing) said my wound care nurse carries out the dietitian recommendations. There should be a weight for 12/14/2023. I do not know why it's not there. On 12/20/2023 an electronic dietary note dated 12/4/2023 from the Dietician indicated a recommendation of to refer to speech therapy for an evaluation, add super cereal and double portions entrée at breakfast and dinner with whole milk 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 observation, interview and record review the facility failed to follow their facility menu for 1 of 4 residents (R75) reviewed for menus in a sample of 23. Findings include: On 12/20/2023 at 12:40pm R75 was observed with a hot dog on her meal tray and was asked did she prefer a hot dog. R75 said no I was looking forward to having roast beef. On 12/20/2023 at 12:50pm V7(Dietary Supervisor) said we did not have enough roast beef after we took it out the oven, so we asked the residents would they like the substitute and they all agreed yes. On 12/20/2023 at 12:52pm V11(Cook) said I did not realize that it was not enough food until I saw the roast come out the oven, then I started cooking hotdogs after we asked who preferred hot dogs instead of roast beef. An order summary sheet indicates that R75 is on a regular diet. Facility Policy: Facility unable to provide a policy.

Based on interview and record review the facility failed to ensure coordination of care and communication between the facility and the hospice provider for 1 of 3 residents (R97) reviewed for hospice care in a sample of 23. Findings include: On 12/21/2023 at 11:30am V12 (Licensed Practical Nurse) was asked how they know what care is provided for R97, a hospice resident. V12 said the staff use the progress notes and she cannot find the notes and it should be in the hospice book for reference. On 12/21/2023 at 1:00pm V3 (Director of Nursing) said the hospice progress notes should be in R97's hospice binder. She not sure why the notes are not there, the progress notes are how we communicate between hospice and the facility. An order summary report dated 12/22/2023 indicates that R97 was placed on hospice on 9/23/2023 and hospice order continued 10/10/2023. Facility Policy: Hospice Services Policy Purpose: To ensure that appropriate services are available to the residents and families and to outline the responsibilities of Hospice Service providers as well as facility staff.…

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 wear appropriate Personal Protective Equipment (N95 mask, face shield, gown, and gloves) when entering a COVID isolation room, failed to change gloves and perform hand hygiene after providing incontinence care for a resident on COVID isolation precautions. This deficiency affects 3 residents (R49, R16 and R95) in the sample of 23 reviewed for Infection Control Management. Findings include: On 12/19/23 at 10:48AM, V30 (Certified Nursing Assistant/CAN) said that she is going to provide morning care to R49. She said that R49 and the other 2 residents (R16 and R95) are on isolation precautions for COVID-19. R49 is located at the corner of the room by the window. V30 prepared all clean linens, gown, disposable brief, and towels/wash clothes and placed it on top of the soiled linen cart she used from other residents. She donned appropriate PPE, and she got inside the isolation room and brought the soiled linen cart with her. The linen cart 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 On 1/10/2023 at 04:15 PM, surveyor observed R45 with V7 (Certified Nursing Assistant/CNA) sitting in his wheelchair in his room. R45 was observed with long dirty nails. R45 said that he wants his nails trimmed. On 1/10/2023 at 04:18 PM, V7 (CNA) said that R45's nails should be trimmed. On 1/12/2023 at 10:35 AM, surveyor observed R45 with V12 (Minimum Data Set/Restorative Registered Nurse/RN) in his room. R45 still had long dirty nails, and R45 said that he wants his nails to be trimmed. On 1/12/2023 at 10:37 AM, V12 said that the restorative CNA is supposed to trim the resident's nails. On 1/12/2023 at 10:39 AM, V10 (Restorative CNA) said that R45 should have his nails trimmed. On 1/12/2023 at 02:50 PM, V2 (Director of Nursing) said that the CNA should trim the residents' nails and if the residents' refuse, CNA should notify the nurse or DON. R45 is a [AGE] year old admitted with diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of R45's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to apply splint to residents with limited range of motion for five (R28, R45, R49, R60, R75) of five residents reviewed for range of motion in a sample of 26. Findings include: 1. On 01/10/2023 at 10:28AM, R75 was observed with left hand contracture without any splints or brace in place. On 01/10/2023 at 10:28AM, R75 stated that she applies the splint herself on Mondays, Wednesdays, and Fridays for a couple of hours. On 01/12/2023 at 10:00AM, V12 (Minimum Data Set/Restorative Registered Nurse) said that R75's splint should be applied daily for the duration of the day as ordered by the physician. On 01/12/2023 at 2:50PM, V2 (Director of Nursing) stated that if a resident has an order for splint or brace, it should be applied as ordered. R75's Order Summary Report dated 01/11/2023 indicated admission date of 12/10/2020, diagnoses including but not limited to cerebral infarction and hemiplegia and hemiparesis following cerebral infarction…

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 urinary catheter bag was covered for 1 of 7 resident (R38) reviewed for dignity in a sample of 26. Findings include: On 1/10/2023 at 10:30am R38 was observed in bed with his urinary catheter bag exposed to roommates. On 1/10/2023 at 10:33am V14 (Licensed Practical Nurse/LPN) said the urinary catheter bag should always be covered. On 1/12/2023 at 2:00pm V2 (Director of Nursing/DON) said all urinary catheter bags should be covered for dignity. An Order Summary Report dated on 1/11/2023 indicated that R38 has a diagnosis of Benign prostatic hyperplasia with lower urinary tract symptoms, presence of urogenital implant, neuromuscular dysfunction of bladder, unspecified. An active order dated 8/30/2022 for an indwelling suprapubic. Facility Dignity policy (1/15) documents: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Responsibility: All Staff. 11. Urinary catheter bags shall be covered.

Based on observation, interview and record review, the facility failed to provide privacy during an injection administration for one (R57) of one resident observed for privacy in a sample of 26. Findings include: On 01/10/2023 at 1:18PM, V11 (Licensed Practical Nurse/LPN) was observed administering a subcutaneous injection to R57 without pulling the privacy curtains or closing the door prior to administration. R57 was in the room with her roommate R11 during this time. On 01/10/2023 at 1:29PM, V11 (LPN) stated that he should have pulled the privacy curtain prior to giving the subcutaneous injection to R57. On 01/11/2023 at 11:15AM, V2 (Director of Nursing) stated that nurses are expected to provide privacy by ensuring curtains are pulled or doors are closed prior to giving any injections to a resident. R57's Order Summary Report indicated admission date of 11/02/2021. R57's diagnoses include but are not limited to heart failure, dementia, essential hypertension, and acute embolism and thrombosis of deep veins of right upper extremity. Facility Medication Administration: Injection -…

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 recommended communication board to one (R36) of one resident reviewed for communication in a sample of 26. Findings include: Review of R36's face sheet documents a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acquired absence of right leg above the knee, Dysphagia, Aphasia following cerebral infarction, Retinal detachment, Right eye, and Major Depressive disorder. On 01/10/23 at 11:37 AM surveyor observed resident who does not talk or have a communication board or a way to communicate. Surveyor observed that the resident shakes head yes and no in response to questions. On 1/11/2023 at 12:24 PM V9 (Certified Nursing Assistant/CNA) and V8 (Nurse) at nurses' station. V9 stated, It is difficult to communicate with R36. He is independent with eating and dressing but needs help showering. V9 stated it is hard 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 reviewed, the facility failed to obtain wound care orders and develop and implement a wound care plan for 1 resident (R256) of 2 residents reviewed for wound care in a sample of 26. This failure resulted in R256 missing wound care treatments. Facility also failed to assess and treat 1 resident's (R39) foot wounds based on physician's orders. Findings include: 1. R256's face sheet documents a [AGE] year old female admitted on [DATE] with diagnoses that include Malignant neoplasm of unspecified site of left female breast and type 2 Diabetes Mellitus. On 1/10/23 at 12:00 PM R256 stated her wound dressings are not being changed regularly. R256 stated she is concerned her wounds will get infected. Surveyor observed wound to left breast without a dressing and 2 round open wounds with yellow necrotic tissue the size of a quarter. V3 (Nurse) stated that R256 is on hospice and the wound care nurse came today to change her wound dressings. On 1/10/2023 at 3:01 PM Surveyor went to…

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

Based on observation, interview and record review the facility failed to ensure that fall prevention interventions were in place for 1 of 7 residents (R18) reviewed for falls in a sample of 26. Findings include: On 1/10/2023 at 10:55am R18's room door was observed closed, the fall mat was observed folded and pushed away from the side of the bed, and the bed was in a high position. On 1/10/2023 at 11:00am V15 (Certified Nursing Assistant/CNA) observed with the surveyor the bed in a high position and the fall mat folded away from the bed. V15 stated R18 is a fall risk. V15 lowered the bed's position, put the fall mat next to the bed and opened the door after leaving. On 1/10/2023 at 11:05am V14 (Licensed Practical Nurse/LPN) stated R18 is a fall risk and fall interventions should always be in place. On 1/12/2023 at 2:30pm V2 (Director of Nursing/DON) stated R18 is a fall risk and should always have all fall interventions in place. An Order Summary Report dated 1/11/2023 indicates R18 has diagnoses including contracted left ankle, syncope and collapse, scoliosis unspecified, 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 provide adequate pain management for one (R100) out of six residents reviewed for pain management in a sample of 26. Findings include: On 1/10/2023 at 10:45 AM, R100 was observed by the surveyor. R100 stated, I am in a lot pain. R100 stated that his pain was in his legs and rated the pain at 9 on a pain scale between 0 - 10 with 0 = no pain, and 10 = highest pain. On 1/10/2023 at 10:50 AM, V3 (Registered Nurse/RN) stated, I just gave R100 acetaminophen 500 mg 2 tablets. On 1/12/2023 at 10:35 AM, surveyor observed R100 with V12 (Minimum Data Set Coordinator/Restorative RN). R100 stated, I am in a lot a pain. R100 stated his pain was in his legs and rated the pain at 10. On 1/12/2023 at 10:36 AM, V3 (RN) stated that R100's pain should be controlled. On 1/12/2023 at 10:40 AM, V19 (RN) stated, I just medicated R100 with acetaminophen 500 mg 2 tablets. On 1/12/2023 at 2:50 PM, V2 (Director of Nursing) stated that the resident's pain 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.

Based on observation, interview and record review, the facility failed to ensure that the refrigerator temperature is monitored and maintained for one (R76) of one resident observed for food storage in a sample of 26. Findings include: On 01/10/2023 at 10:34AM, R76's refrigerator was observed without any thermometer and temperature log. On 01/11/2023 at 11:10AM, R76's refrigerator was again observed without any thermometer and temperature log. On 01/11/2023 at 11:18AM, R76's refrigerator was observed with V2 (Director of Nursing) and confirmed that the fridge has no thermometer and temperature log. V2 stated that there should be a thermometer and temperature log, and certified nursing assistants and nurses should check the temperature daily. R76's Order Summary Report dated 01/11/2023 indicated admission date of 10/28/2022 and diagnoses including but not limited to adult failure to thrive, anemia, essential (primary) hypertension and severe protein-calorie malnutrition. Facility Food Storage - Outside Sources policy (Date: 1/19) documents . Foods or beverages brought in from 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.