Alden Estates Of Orland Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices during blood glucose monitoring and dining service. This applies to 5 of 5 residents (R16, R5, R98, R133, R221) reviewed for infection control in a sample of 36. The findings include: 1. On October 1, 2024 at 11:57 AM, V45 (LPN/Licensed Practical Nurse) went from R29's room and performed a blood glucose test on R29. V45 left R29's room after getting the blood glucose results and returned to her nurse cart. V45 inputted R29's blood glucose level into the computer, then grabbed her supplies again and went to R16's room. V45 did not clean the glucometer before testing R16's blood glucose level. On October 3, 2024 at 2:15 PM, V19 (LPN) said she would wipe down the blood glucose monitor after each resident as it was a precaution for infection control. On October 3, 2024 at 2:34 PM, V21 (LPN) said he would wipe down the glucometer between residents with the wipes. V21 said the wipes container also told them…

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.

2. On 10/01/24 at 11:36 AM R155 was in his bed and his call light was under his bed out of his reach, at 11:37 AM V7 (Nurse) came in the room to assist R155 with his TV and then left the room and did not put the call light within R155 reach before leaving the room. At 12:25 PM R155 was in his bed and his call light was observed still under his bed out of his reach. At 01:20 PM R155 was in his bed and his call light was still on the floor under his bed out of his reach. On 10/02/24 at 08:33 AM R155 was in his bed and his call light was seen under his bed out of his reach. V6 (Nurse) was in R155's room at that time providing care for R155, and when V6 left the room, she did not put R155's call light within reach for R155. On 10/03/24 at 09:52 AM R155 was in his bed and his call light was under his bed. V4 (Nurse) was called into the room, and she said that R155 is able to use his call light and he does use it but with it under the bed he is unable to reach it or use it. On 10/03/24 at 02:33 PM V1 (Administrator) said that the call light should be within reach so that the resident can…

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 resident and/or family/power of attorney written documentation of bed hold notification when residents were transferred to the hospital. The facility also failed to notify the ombudsman of the transfer. This applies to 3 of 5 residents (R105, R146 and R159) reviewed for discharge and hospitalization in a sample of 36. The findings include: 1. R105's After Visit Summary shows that R105 was admitted to the hospital from [DATE] to 8/28/24 and was treated for Elevated Troponin levels. R105's progress notes of 8/25/24 at 1:20 PM states that R105 was sent to the emergency room (ER) for swelling to bilateral ankle, daughter was at the facility, and was notified of the transfer. 2. R159's Hospital record shows that R159 was admitted to the hospital from [DATE] to 9/7/24 with diagnoses of sepsis due to unspecified organism. R159's progress notes of 8/30/24 at 4:40 PM shows that R159's abnormal lab was reported to the doctor, and the ordered for R159 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 ensure intravenous medications were administered by qualified staff. This applies to 1 of 1 resident (R165) reviewed for intravenous therapy in a sample of 36. Findings include: R165 admitted to the facility on [DATE] with diagnoses that includes orthopedic aftercare following surgical amputation, acute osteomyelitis right ankle and foot, type 2 diabetes and cellulitis of right lower limb. R165 current physician orders include Daptomycin 700 MG (Milligrams) a day until 10/09/2024 and Ceftriaxone 2GM (Grams) a day until 10/09/2024. On 10/03/24 at 05:14 PM, V13 LPN (Licensed Practical Nurse) stated she administered R165's IV (Intravenous) antibiotic at 9:30 AM. V13 stated she flushed the midline PICC (Peripherally Inserted Central Catheter) and changed the cap that morning. On 10/3/24 at 6:01 PM, V2 DON (Director of Nursing) stated only RNs (Registered Nurses) should be hanging IV's, disconnecting them or changing the dressing. The LPN should know they…

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 a skin alteration worsening assessed by a physician? This applies to 1 of 1 resident (R16) reviewed for quality of care in a sample of 36. The findings include: On October 1, 2024 at 12:17 PM, R16 said she had a diaper rash. At 12:23 PM, V29 (CNA/Certified Nurse Assistant) and V30 (CNA) came to R16's room and provided incontinence care for R16, as she had a bowel movement. When R16's incontinence brief was removed, R16 had reddened and inflamed skin from her lower back to the upper thigh areas, as well as her perineal area, and her folds. V29 and V30 wiped R16's perianal area and applied a barrier cream to her perianal area but did not apply the cream to the perineal area or the folds. R16 said she felt like her skin was on fire on her bottom. On October 3, 2024 at 9:08 AM, V34 (Wound Care Coordinator) said R16 was not being seen for wound rounds. On October 3, 2024 at 4:02 PM, surveyor and V34 did a skin check for R16. V34 said R16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer restorative services to a resident as recommended per the admission restorative nursing assessment. This applies to 1 resident (R152) reviewed for restorative services in a sample of 36. The findings include: R152's Face Sheet shows he was admitted to the facility on [DATE]. On 10/1/24 at 12:27 PM, R152 said he had been in the facility for about 4 months and he was not too happy because he had just found out that he was supposed to be getting rehab services, but he had not received any therapy services at all since his admission. R152's Functional Abilities and Goals admission assessment dated [DATE] documented by V7 (Restorative Registered Nurse) shows R152 had no impairment to his upper and lower extremities, was completely dependent on staff for toileting hygiene and had a discharge goal to improve to only require substantial assistance with toileting hygiene, and was completely dependent on staff during bed mobility/rolling left and right in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe supervised environment. This applies to 3 of 4 residents (R221, R222, & R142) reviewed for free of accidents, hazards, supervision and devices in a sample of 36. The findings include: 1. On 10/01/24 at 01:30 PM, R221 was observed in his wheelchair by the nursing station without his shoes or eyeglasses on, and the socks he had on were not non-skid socks. R221 was observed trying to get up from his wheelchair and appeared confused and had difficulty understanding staff's request when asked to see the bottom of his feet. V37 (Nurse) said he is to have non-skid socks on. V38 CNA (Certified Nurse's Assistant) said that she was the staff that assisted him with dressing that morning and she observed him taking his shoes off, but she did not put non-skid socks on him after seeing him taking off his shoes. V38 said that she should have put the non-skid socks on R221 because he is a fall risk. R221 electronic health record showed…

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 change a soiled PICC midline PICC (Peripherally Inserted Central Catheter) as needed. This applies to 1 of 1 resident (R165) reviewed for intravenous therapy in a sample of 36. Findings include: R165 admitted to the facility on [DATE] with diagnoses that includes orthopedic aftercare following surgical amputation, acute osteomyelitis right ankle and foot, type 2 diabetes and cellulitis of right lower limb. R165 current physician orders include IV (Intravenous) Midline: transparent sterile dressing change weekly and PRN (as needed). Check IV site every eight hours for unusual redness, drainage and skin irritation, site pain etcetera and document condition. On 10/01/24 at 01:43 PM, R165's showed the surveyor his left upper arm PICC line. The PICC insertion was covered by a gauze and transparent dressing dated 9/29. On 10/03/24 at 11:48 AM, R165 showed the surveyor his PICC line. The gauze under the transparent dressing had bloody drainage on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide oxygen supplementation as ordered by the physician. This applies to 1 of 2 residents (R42) reviewed for oxygen therapy. Findings include: R42 admitted to the facility on [DATE] with diagnosis that includes encounter for palliative care, adult failure to thrive, chronic obstructive pulmonary disease, hypertension, anxiety and dependence on supplemental oxygen. R42's Physician orders include oxygen 4 liters per minute per nasal cannula continuous. On 10/01/24 at 11:32 AM, was in bed with a nasal cannula connected to an oxygen compressor set to 0 Liters. R42 tongue was blue, and her respirations were shallow. On 10/01/24 11:47 AM, V6 RN (Registered Nurse) assigned to R42 stated she did not turn the oxygen supply off and did not know who did. V6 stated R42 physician order is for 4L (liters) per minute to be administered. On 10/03/24 at 11:35 AM, R42 had nasal cannula connected to an oxygen compressor set to 4L. R42's tongue was pink 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 have an accurate Record of Receipt for a controlled medication. This applies to 1 of 1 resident (R324) reviewed for Record of Receipt for controlled medications. The findings include: On 10/03/24, at 10:00 AM, During the observation of the third floor (split) medication cart, a handwritten note on white copy paper was in the Controlled Drug Receipt/Record/Disposition Form book. The handwritten note contained R324's name and directions as followed: take 5 mg (0.25mL) by mouth or sublingual every hour as needed for pain, shortness of breath. May titrate in 5 mg (0.25 mL) increments up to. The handwritten note did not contain the medication's name, quantity on hand, quantity received, or licensed nurses signatures. R324 had a box of Morphine Sulfate 30 mL in the locked box on the medication cart. On 10/03/24 10:07 AM V2 (Director of Nursing) stated R324 did not have the appropriate narcotic count sheet. The medication name of Morphine…

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 sufficient nursing staff to ensure residents' needs were met. This applies to 4 of 4 residents (R1, R2, R6, and R7) reviewed for lack of staff in the sample of 10. Findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and was sent to the local hospital, per R1's request, on November 17, 2023. R1 did not return to the facility. R1 had multiple diagnoses including, chronic ulcerative pancolitis with complications, ileostomy care, hemiplegia and hemiparesis following cerebral infarction, heart failure, acute kidney failure, muscle weakness, abnormal gait, urine retention, recurrent depressive disorders, atrial flutter, cardiomyopathy, epilepsy, and anxiety disorder. R1's MDS (Minimum Data Set) dated October 4, 2023 shows R1 had moderate cognitive impairment, was able to eat independently, required supervision with toilet hygiene and bed mobility, and required partial/moderate…

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 received assistance with dressing and changing soiled clothing. This applies to 2 of 3 residents (R2 and R6) reviewed for improper nursing care in the sample of 10. The findings include: 1. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, heart failure, acute kidney failure, atrial fibrillation,, dysphagia, gastrostomy, Takotsubo syndrome (stress cardiomyopathy), right knee laceration, incontinence, sacral pressure ulcer, COPD (Chronic Obstructive Pulmonary Disease), anemia, aortic stenosis, and diverticulosis of the large intestine. R2's MDS (Minimum Data Set) dated November 7, 2023 shows R2 is cognitively intact, has a colostomy, and is frequently incontinent of urine. R2's MDS continues to show R2 requires partial/moderate assistance with upper body dressing and is dependent on facility staff for lower body dressing. R2's care plan, initiated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders to record the total volume of tube feeding infused each shift to ensure a resident received tube feeding administration as ordered. This applies to 1 of 3 residents (R6) reviewed for tube feeding use and weight loss in the sample of 10. Findings include: The EMR (Electronic Medical Record) shows R6 was admitted to the facility on [DATE]. R6 was sent to the local hospital on October 19, 2023 and returned to the facility on October 21, 2023. R6 has multiple diagnoses including cerebral infarction, malignant tumor of the oropharynx, chronic respiratory failure, tracheostomy, muscle weakness, abnormal gait, gastrostomy, pleural effusion, dysphagia, dental caries, COPD (Chronic Obstructive Pulmonary Disease), atrial fibrillation, dependence on oxygen, and radiation therapy. On November 29, 2023 at 9:48 AM, R6 was lying in bed in his room wearing a hospital gown. R6 was not able to answer questions due to his medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was transported to a radiation/oncology appointment in a timely manner and family and physician were notified for 1 of 3 residents (R1) reviewed for quality of care on the sample list of 6. Findings include: R1's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: malignant neoplasm of oropharynx, chronic respiratory failure, tracheostomy, klebsiella pneumoniae, atrial fibrillation, chronic obstructive pulmonary disease, pleural effusion, dysphagia and gastrostomy. R1's After Visit Summary dated 10/4/23 shows that his last radiation treatment was on 10/4/23 and had a follow up scheduled with V13 (Oncologist) on 11/1/23 at 2:30 PM. On 11/21/23 at 1:00 PM, V13's office staff verified that R1 had scheduled appointments with V13 on 11/1, 11/8, and 11/16 but did not show up to any of them. R1's Nursing Notes dated 11/1/23 at 11:30 AM shows, Resident miss appointment today due to transportation issues, will…

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 timely ADL (Activities of Daily Living) care to residents that required staff assistance. The facility also failed to completely rinse off the soap from a resident's body during provisions of care. This applies to 4 of 6 residents (R84, R113, R131, R136) reviewed for activities of daily living on the sample list of 33. Findings include: 1. R84's EMR (Electronic Medical Record) showed R84 admitted to the facility on [DATE] with diagnoses that included unspecified dementia with anxiety, major depression, chronic obstructive pulmonary disease, atrial fibrillation, and spondylosis with radiculopathy. R84 admitted to hospice care on 9/29/22. R84's MDS (Minimum Data Set) dated 10/13/23 showed R84 had severely impaired cognition for decision making. R84's annual MDS on 9/26/23 showed R84 required one staff physical assistance for transfers and toilet use. R84's Care Plan showed R84 has an ADL self-care performance deficit secondary 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, record review, the facility failed ensure residents received oxygen therapy as ordered by the physician during multiple observations. This applies to 2 of 2 resident (R5, R149) reviewed for oxygen therapy on the sample list of 33. Findings include: 1. R5's face sheet documents R5 admitted to the facility on [DATE] with diagnoses that include Respiratory failure, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, and Chronic Diastolic Heart Failure. R5's physician order summary shows the following order dated 11/5/2023: Respiratory: oxygen per nasal cannula at 3 liters per minute continuous every shift. On 11/06/23 at 02:59 PM, R5 was sitting and crying out at the nurse's station and appeared uncomfortable. R5's nasal cannula was partially in R5's nose and it did not sound like the oxygen tank was on. Surveyor asked V24 Certified Nursing Assistant (CNA) if she could check oxygen (O2) tank. The oxygen tank was empty. V37 Licensed Practical Nurse (LPN) checked R5's O2…

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 infection prevention control measures and follow facility policy related to hand hygiene while providing care and during medication administration. This applies to 4 of 7 residents (R3, R131, R136, R148) reviewed for infection prevention in the sample of 33. The findings include: Facility's Policy and Procedure for Hand Washing and Hand Hygiene dated 6/4/20 indicates: Purpose: Appropriate hand hygiene is essential in preventing the spread of infectious organisms in healthcare settings. Guidelines: 1. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items. Specific examples include: c. Before touching medication or food to be given to a resident. e. Before and after providing personal care to a resident. f. After removing gloves. g. After touching any item or surface that may have been contaminated with blood or body fluids, excretions, or secretions. 1. R136's Face Sheet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer the influenza and pneumonia vaccines to residents residing in the facility. This applies to 5 of 5 residents ( R3, R15, R56, R76, R148) reviewed for influenza and pneumonia vaccines in the sample of 33. Findings include: 1. R3's EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE] with diagnoses including chronic systolic (congested) heart failure, hypertensive heart disease with heart failure, atrial fibrillation, and nonrheaumatic aortic valve stenosis. R3's immunization record provided by the facility showed there was no pneumonia vaccine offered. 2. R15's EMR showed R15 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, post traumatic seizures, gastrostomy tube, chronic respiratory failure, chronic obstructive pulmonary disease, protein-calorie malnutrition, dependence on supplemental oxygen, personal history of traumatic brain injury, and encephalopathy. R15's immunization record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that residents have access to their trust fund money when requested. This failure affects 1 of 2 residents (R36) reviewed for personal funds in a sample list of 33. The findings include: Review of R36 face sheet documents R36 admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, morbid obesity, Type 2 Diabetes, and Myocardial Infarction. On 11/6/23 at 11:38 AM, R36 stated that the facility takes his money right away, but they take a long time to give him his 30 dollars every month. R36 states sometimes it takes weeks to get his money and it is not consistent. The following are the dates and amounts R36 signed for trust fund money according to the Trust Fund Signature Forms: 2/9/23, $30 3/1/23, $100 4/17/23, $30 5/4/23, $30 6/28/23, $60 8/2/23, $30 9/21/23, $30 10/12/23, $30 11/6/23, $30 On 11/8/23 10:57 AM, V21 (Business Office Manager) stated she has a list of residents who always want their $30 every month. V21…

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.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to identify a resident who actively smokes and secure smoking paraphernalia. This failure affects one of two residents (R149) reviewed for accidents and supervision on the sample list of 33. B. Based on observation, interview and record review, the facility failed to ensure safe positioning of a resident and required number of staff for safety while providing care for one of two residents (R136) reviewed for accidents and supervision on the sample list of 33. Findings include: a.) R149's face sheet included diagnoses of chronic obstructive pulmonary disease with (acute) lower respiratory infection, acute bronchitis, unspecified, pneumonia, unspecified organism, acute respiratory failure with hypoxia, dependence on supplemental oxygen. R149's admission MDS (Minimum Data Set) dated 8/4/23 showed that R149 was cognitively intact. R149's POS (Physician Order Sheet) included order for Oxygen per nasal cannula at 3 liters per minute…

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 a resident identified as having a significant weight loss received his gastrostomy tube feeding as ordered by the physician to prevent further weight loss. This failure affects 1 of 3 residents (R148) reviewed for nutrition on the sample list of 33. Findings include: R148's Face Sheet documents R148 has multiple diagnoses including nontraumatic intracerebral hemorrhage, chronic respiratory failure with hypoxia, encephalopathy, dependence on respirator (ventilator) status, gastrostomy, dysphasia (oropharyngeal phase), type 2 diabetes mellitus. R148's electronic vital signs documentation showed the following weights: 8/14/2023 - 178.4 lbs (pounds); 9/20/2023 - 176.8 lbs; 9/23/2023 - 164.0 lbs; 10/1/2023 - 166.2 lbs; 11/2/2023 -157.8 lbs. Based on the above documented weights, R148 had an 8.4 lbs weight loss, equivalent to 5.05% significant weight loss in one month, from 10/1/23 to 11/2/23. R148 had a 20.6 lbs significant weight loss, equivalent to 11.54% weight loss in less than three months, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to change the resident's midline dressing to ensure integrity of the catheter and to prevent potential intravenous site infection. The facility also failed to document the midline site/location, as well as the baseline external midline catheter length and mid-arm circumference per policy and procedure. This applies to 1 of 2 residents (R213) reviewed for intravenous lines on the sample list of 33. Findings include: R213 was originally admitted to the facility on [DATE]. R213's Face Sheet documents R213 has multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, adult failure to thrive, gastrostomy infection, dysphasia following cerebral infarction and type 2 diabetes mellitus. R213's change in condition evaluation showed that the resident was transferred to the hospital on [DATE] due to concerns with R213's intravenous line. R213's hospital records dated 10/29/23 showed, (R213) had…

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 medications were administered according to the physician's orders. There were 2 medication errors out of 25 opportunities, resulting in an 8% medication error rate. This applies to 1 of 8 residents (R148) reviewed during medication administration on the sample list of 33. Findings include: On 11/7/23 at 1:15 PM, V25 (Nurse) administered multiple medications to R148 which include Hydralazine (Vasodilator) 100 milligram (mg) tablet and Isosorbide (Nitrate) 20 mg tablet. These medications were crushed and diluted in water to be administered via R148's gastric tube. During medication administration, V25 accidentally knocked over the Isosorbide and spilled about 1/2 of the diluted medication. V25 immediately picked it up and poured additional water to the cup then he administered it. V25 did not obtain a full dose of Isosorbide to ensure a full dose was administered as ordered. After V25 administered the Isosorbide, he administered the Hydralazine without stirring the cup. There was Hydralazine sediment…

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 label and date medications after it was opening and failed to remove/dispose of used/open medications of residents that no longer resided in the facility. This applies to 2 of 5 residents (R133, R148) reviewed for labeling, storage, and expiration of drugs in the sample of 33. The findings include: On 11/8/23 at 12:32 PM medication cart (cart #3) inspection was conducted with V14 (Nurse) on the 2nd floor unit of the facility. The following were observed: -R148's Insulin Glargine Pre-filled pen was opened and not dated. This medication should be discarded 28 days after it was opened according from pharmacy recommendation. - There was a Fluticasone Propionate Nasal Spray (Corticosteroid) in this cart that was opened, not dated and was not labeled with resident's name. On 11/8/23 at 12:47 PM, the medication room on the 2nd floor was inspected with V35 (Nurse). The following medications were stored in the refrigerator on the 2nd floor: - R133's Insulin Lispro Kwik Pen was opened and not dated. The pharmacy…

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 therapeutic diets as per physician orders. This applies to 2 of 2 residents (R43, R133) reviewed for dining on the sample list of 33. The findings include: 1. R43's diagnoses on face sheet included dysphagia, oropharyngeal phase, gastro-esophageal reflux disease without esophagitis, chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia. R43's POS (Physician Order Sheet) showed diet order of General diet, Mechanical Soft texture, Thin Liquids consistency, No Straws (start date 10/17/23). On 11/7/23 at 12:20 PM, R43 was seated up in bed and eating lunch from a bedside table. R43 received a mechanical soft consistency meal with a glass of lemonade with a straw. R43 had no meal ticket by her meal tray. V12 (R43's son) who came into the room stated She always uses a straw. It comes down with the meal and she puts it in there [in cup of lemonade]. R43 then remarked that the doctor had told her that it is not good to use the straw. R43's dietary care plan…

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 ensure resident's care needs were met. This applies to 4 of 5 residents (R2, R3, R4, R8) reviewed for ADLs (Activities of Daily Living)on the sample list of 8. The findings include: 1. The EMR (Electronic Medical Record) shows R2 had diagnoses including chronic respiratory failure, dysphagia, hydrocephalus, intracerebral hemorrhage, epilepsy, encephalopathy, gastrostomy status, tracheostomy, diabetes mellitus, anemia, hypertension, aphonia, and cerebrospinal fluid drainage device. R2's MDS (Minimum Data Set) dated 7/25/23 showed R2 had severe cognitive impairment and was dependent on staff for oral hygiene, toileting, showering/bathing, dressing, bed mobility, and transferring. R2's care plans showed to turn and reposition R2 every two hours and as needed due to risk of alteration in skin integrity secondary to impaired mobility/totally dependent on staff. On 10/26/23 at 12:51 PM, R2 was in bed. R2 was facing towards the door. R2 had wedges…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide sufficient nursing staff to meet the residents' needs. This applies to 4 of 4 residents (R2, R3, R4, R8) reviewed for staffing on the sample list of 8. The findings include: 1. On 10/26/23 at 12:51 PM, R2 was not repositioned according to his turn schedule posted behind his bed. V22 (CNA/Certified Nurse Assistant) said she had not turned R2 during her shift. V22 said she had been unable to turn R2 according to the turn schedule during her shift from 6 AM to 2 PM because of the care she had needed to provide to other residents. R2's MDS (Minimum Data Set) dated 7/25/23 showed R2 had severe cognitive impairment and was dependent on staff for ADLs (Activities of Daily Living). 2. On 10/19/23 at 11:32 AM, R3 said he needed incontinence care. V26 (Family Member) said R3 had a rash on his bottom. At 11:59 AM, R3 had his call light answered by V29 and R3 and V26 requested incontinence care. At 01;18 PM, R3 was provided incontinence care by V8 (Wound…

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 administer intravenous antiviral medications to 1 resident (R1) as ordered by the physician. This failure affects 1 of 3 residents (R1) reviewed for medication administration in the sample of 3. The findings include: R1 was admitted to the facility 1/19/23 and was discharged from the facility 1/22/23 per the admission face sheet. The physician order sheet dated 1/19/23 showed R1's diagnoses including arthrodesis of the spine, severe kidney disease stage 4, pain in the back, metabolic encephalitis, coronary artery disease and history of falls. The physician order sheet dated 1/20/23 showed that on 1/21/23 R1 was to start getting intravenous antiviral medication once every 12 hours for prophylaxis. The MAR (Medication Administration Record) showed that R1 was only given one dose on 1/22/23 at 6:00am. The doses for 1/21/23 at 6am and 6pm were not given. There is no documentation in R1's progress notes to explain why. There is no documentation of a physician's order to hold the medication on those dates/times. On 10/12/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist residents with ADLs (Activities of Daily Living) who require assistance for personal hygiene, showers, and toileting. This applies to 11 of 11 resident's (R9, R25, R28, R43, R50, R58, R84, R89, R121, R336, R433) reviewed for activities of daily living in the sample of 32. The findings include: 1. On 1/5/23, R121 smelled strongly of urine, and his fingernails were half an inch long with dirt underneath them. R121 is nonverbal but nodded 'yes' when asked if he wanted his nails cut. R121 shook his head 'no' when asked if anyone had offered to cut his nails. The MDS (Minimum Data Set) dated 11/14/22 showed R121 requires limited assist of one with toileting and personal hygiene. R121's Care Plan dated 11/10/22 shows R121 requires assist with daily care needs. 2. On 1/3/23, R28 observed with long facial hair and nails that were dirty, jagged, and some one inch in length. R28 stated he wanted his nails cut and his facial hair removed. 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 provide a hazard-free environment by insecurely storing metal oxygen tanks in the resident rooms. This applies to 5 of 6 residents (R288, R289, R129, R287, and R290) reviewed for accidents and hazards in a sample of 32. Findings include: On 1/3/23 at 12:18 PM, R288 was observed in his bed and a metal oxygen tank unsecurely stored at the bedside without a holder stand or chained to the wall to prevent cylinder from tipping over. The surveyor observed R289 sharing the room with R288. On 1/3/23 at 12:40 PM, the surveyor observed V13 (Director of Nursing) removing the metal oxygen tank from the resident room and stated, Oxygen tanks can be stored in the resident room, but it should be secured with a stand. On 1/3/23 at 12:30 PM, observed R129, R287, and R290's rooms in close proximity to R288's room. The facility presented an oxygen storage policy dated 09/2020: All oxygen containers (compressed tanks and liquid cylinders) will be restrained while in storage.

Based on observations, interviews, and record reviews, the facility failed to maintain infection control practices while providing care to 4 residents (R336, R106, R292 and R283) that were reviewed for infection control in a sample of 23. Findings include: 1. On 1/4/24 at 11:52 am V9 (Nurse) was providing catheter care for R336. R336 is on enhanced barrier precautions requiring staff to wear gowns and gloves when providing patient care. R336 has diagnoses including osteomyelitis, local infection of the skin, open wounds to the lower back, and Proteus Mirabilis (bacterial infection). V9 only donned gloves, she did not don a gown. While V9 was providing catheter care for R336, V9 removed her dirty gloves after cleaning R336's perineal area, put new gloves on but did not wash her hands. V9 then emptied R336's catheter bag, touched the package of disposable wipes, emptied the urine in the toilet, and flushed the toilet with her unclean hands. V9 then picked up the wipes that had been touched with her unclean hands and put the disposable wipes on her medication cart. On 1/4/23 at 11:59…

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 accommodate a resident's choice to be relocated to another unit within the facility. This applies to 1 of 1 resident's (R92) reviewed for choices in a sample of 32. The Findings Include: R92 was observed on 1/3/23 at 1:23 pm sitting at a dining table reading a book. Resident was noted to be clean and well dressed. On 1/3/23 at 1:23 pm R92 stated she did not belong on the memory care unit. R92 stated, she had resumed smoking again because being on that unit caused her stress and boredom. R92 stated smoking was the only way for her to get fresh air and a change of scenery. R92 stated she was placed there to get herself together, but she had improved and no longer needed to be on a locked unit. R92 stated she does not have any freedoms or anyone to converse with on that unit. R92 stated she is unable to sleep at night because the other residents are up all night yelling. R92 stated she does not participate in the activities because they are…

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 standards of care and their gastrostomy tube (GT) policy by not flushing between medication administrations for residents with G-Tubes. This applies to 2 of 2 residents (R81 and R88) reviewed for GT medication administrations. Findings include: 1. On 01/04/23 at 1:01 PM, during medication pass, observed V6 (Registered Nurse) administering GT medications to R88. V6 administered Midodrine 10 milligram (mg), Metoprolol 50 mg, and Bromocriptine Mesylate 5 mg via GT without flushing between each medication. 2. On 01/04/23 at 1:15 PM, during medication pass, observed V6 (Registered Nurse) administering GT medications to R81. V6 administered Gabapentin 900 mg/18 milliliter (ml) and Reglan 10mg/10ml via GT without flushing between medications. On 01/04/23 at 1:10 PM, V6 stated that the resident would get too much fluid if he flushed in between medications; hence, he doesn't need to flush between medications. On 01/04/23 at 02:00 PM, V2 (Director of Nursing) stated that Staff is supposed to flush between GT…

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

Based on observations, interviews, and record reviews, the facility failed to apply hand splints/palm protectors to 2 residents (R79 & R84) that were reviewed for limited Range of Motion (ROM) to prevent contractures in the sample of 32. Findings include: 1 On 1/3/23 at 11:05am, R84 was observed in his bed with no splint/palm protector to his left hand. His left hand was observed contracted. On 1/4/23 at 11:21am R84 was observed in the TV room with no splint/palm protector on his left hand. R84's 5/24/22 physician order showed, palm protector to left hand. R84's 11/27/22 care plan showed R84 is to wear a palm protector to his left hand for restorative care. 2 On 1/3/23 at 11:48am R79 was observed in bed with no splints/palm protectors on his hands. R79's 2/26/20 physician order showed, apply palm protectors to left hand and apply soft pro grip wrist hand finger orthotic to right hand. R79's 8/16/22 care plan showed R79 requires palm protectors to both hands secondary to contracture. On 1/5/23 V2 DON (Director of Nursing) said R79 should have had splint/palm protectors on while he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide proper catheter care for 2 residents (R286 & R336) that were reviewed for catheter care in a sample of 32. Findings include: 1 On 1/4/23 at 11:52am V9 (Nurse) was providing catheter care for R336. V9 wiped the left and right side of R336's thighs and R336's perineal area but did not wipe or clean R336's catheter tubing. On 1/4/23 at 11:59am V9 said she didn't clean R336's catheter tubing because she was nervous. V9 said she should have cleaned the tubing because of infection control. On 1/5/23 at 12:53pm V2 DON (Director of Nursing) said the nurse should clean the catheter tubing because it can cause urinary tract infections, yeast infections, or any bacteria that's on the catheter tubing. The facility Catheter Care policy dated September 2020 shows under Policy, Daily and PRN catheter care will be done to promote comfort and cleanliness. Procedure: #12 Wash catheter itself by holding onto catheter at insertion site washing…

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 appropriately position a resident during G-tube (Gastrostomy Tube) infusion to minimize the risk of aspiration. This applies to 1 of 1 residents (R123) reviewed for positioning with G-tubes in the sample of 32. The findings include: R123's face sheet showed R123 was admitted to the facility on [DATE] and his diagnoses include tracheostomy, ventilator dependent, and gastrostomy dependent. R123's MDS (Minimum Data Set) dated 12/16/22, showed R123 had severe cognitive impairment and was totally dependent on staff for activities of daily living. On 1/3/23 at 11:25 AM, R123 was lying flat in bed with a G-tube feed on and infusing. On 1/4/23 at 9:26 AM, R123's head of bed was at 10 degrees with the G-tube feed infusing at a rate of 50 ml/hr (Milliliters/Hour). On 1/4/23 at 2:02 PM, V19 (CNA/Certified Nurse Assistant) said the head of the bed should be up while the G-tube is running because the resident could choke. On 1/4/23 at 2:10 PM, V6…

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.