Warren Barr Orland Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents who require assistance with their ADLs. This applies to 7 of 7 residents (R23, R29, R33, R68, R75, R96, R116) reviewed for personal hygiene in a sample of 33. The findings include: 1. On 4/8/25 at 10:59 AM, R96 was lying in bed. His hair was disheveled and greasy. V33 (R96's wife) was beside him and she stated, They never wash or comb his hair. R96 confirmed what V33 had said. R96's care plan, dated 3/4/25, shows she has a ADL self care performance deficit and impaired mobility related to disease process. Intervention: Dressing and grooming (R96) .groom self and wash body and comb hair daily. R96's face sheet shows diagnoses of major depressive disorder, single episode, unspecified and suicidal ideations. 2. On 4/8/25 at 11:37 AM, R116 was lying in bed. He had a full beard and very long nails with a dark substance underneath on both hands. R116 stated, I've been asking to be…

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

Based on interview and record review, the facility failed to obtain vital information regarding residents' pacemakers, and ensure it was readily available in the resident's medical record. This applies to out 5 of 5 residents (R20, R81, R96, R136, R529) reviewed for pacemakers in a sample of 33. The findings include: 1. R81's face sheet documents an admission date of 6/15/23. R81's POS (Physician Order Sheet) shows an order (6/16/23) for Pacemaker-Check for functionality and effectiveness. Check pulse rate and blood pressure daily and as needed. R81's face sheet documents the following diagnoses: presence of cardiac pacemaker, chronic combined systolic (congestive) and diastolic (congestive) heart failure, pure hypercholesterolemia, hyperlipidemia, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential (primary) hypertension, and hypertensive heart disease with heart failure. R81's medical record was reviewed. R81's progress notes, admission assessment, and care plan do not document the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove expired items from resident refrigerators. This applies to 4 of 4 residents (R36, R38, R47, R84) reviewed for refrigerators in a sample of 33. The findings include: 1. On 4/08/25 at 12:07 PM, inside R38's fridge, she had two cartons of yogurt (113 grams). One carton was raspberry flavored which expired on 12/3/24, and the other one was strawberry flavored that expired on 10/13/24. There was a carton of (gelatin) with a best by date of 10/8/24. R38 stated, I didn't know those were expired. You can throw those out. I won't eat those. I don't wanna get sick. R38's face sheet shows diagnoses of dysphagia, prediabetes, impaired glucose tolerance, cachexia and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R38's MDS (Minimum Data Set), dated 1/10/25, showed R38 is cognitively intact. 2. On 4/08/25 at 12:30 PM, inside R36's fridge, there were 2 cartons of yogurt (113 gram) mixed berry flavor 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.

Based on observation, interview, and record review, the facility failed to follow infection control measures. These failures apply to 5 of 5 residents (R27, R5, R529, R383, & R63) reviewed for infection control practices in a sample of 33 residents. The findings include: 1. On 04/08/25 at 12:35 PM, V3 (Restorative) was sitting at a table; R529 was to V3's left, and R63 was to her right. V3 was feeding R529 with her right hand, and then put down R529's fork, and V3 got up to move R63's wheelchair, touching the wheelchair. V3 then touched R63's lunch tray that R63 was eating his lunch from. After touching R63's wheelchair with both hands and touching R63's tray with her right hand, V3 then opened R529's mustard and ketchup packets with R529's fork, and then put a forkful of hamburger into R529's mouth. V3 never cleaned her hands between handling R63's wheelchair and tray and then feeding R529. At 12:54 PM, V3 was still feeding R529 with her right hand, and she reached over with her right hand and handed R63 his drink, and then turned back to R529 and put a forkful of hamburger in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or their representative of the facility's policy for bed hold in writing. This applies to 3 of 3 residents (R33, R54, and R80) reviewed for discharge in a sample of 33. The findings include: 1. R33's Face Sheet showed R33 was admitted to the facility on [DATE]. R33 had multiple diagnoses which included monoplegia of upper limb, Alzheimer's Disease, cerebral ischemia, diabetes, vascular dementia, and hypertension. R33's Change in Condition with SBAR (Situation, Background, Assessment, Recommendation) Form, dated 12/20/24, showed R33 was observed sitting on the floor, next to her bed. The same form showed R33 was transferred to the hospital via emergency medical transport on 12/20/24. The form showed the facility's bed hold policy was not given to the resident and or/representative. The EMR (Electronic Medical Record) contained no documentation showing the bed hold policy was given to R33 and/or the representative. The facility…

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

Based on observation, interview, and record review, the facility failed to ensure resident beds were kept at a safe height. This applies to 2 of 4 residents (R167 and R173) reviewed for accidents in a sample of 33. Findings include: 1. On 04/10/25 11:59 AM, R167's bed and over bed table were in a very high elevated position. On 04/10/25 at 12:00 PM, R167 stated his bed was dangerous. V35, PTA (Physical Therapy Assistant/Therapy Director), entered R167's room and stated, The bed should not have been left that high. If (R167) had fallen from bed the impact of an injury would be worse. R167's diagnoses includes sequelae of cerebral infarction, hypertension, muscle wasting and atrophy. R167's care plan showed R167 was at risk for falls, with interventions include to provide a safe environment. 2. On 04/08/25 at 12:55 PM, R173's bed and over bed table were in a high position. On 04/08/25 at 12:57 PM, V29, Certified Nursing Assistant/CNA, stated R173 was a high fall risk. V29 stated she left R173's bed in the high position. R173's diagnoses includes displaced intertrochanteric fracture of…

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

Based on observation, interview, and record review, the facility failed to store medications securely. This applies to 3 of 3 residents (R125, R119, R379) reviewed for medication storage in a sample of 33. The findings include: 1. R125's face sheet showed R125 was admitted to the facility with diagnoses muscle wasting and atrophy, abnormalities of gait and mobility, aftercare following joint replacement surgery, intervertebral disc disorders with radiculopathy lumbar region, rheumatoid arthritis, unilateral primary osteoarthritis right knee, and osteoarthritis. R125's POS (Physician Order Sheet) did not have an order for Biofreeze Roll On Pain Relieving Gel. On 4/8/25 at 11:43 AM, R125's had a Biofreeze Roll On Pain Relieving Gel sitting on her bedside table. On 4/10/25 at 10:19 AM, R125's bedside table had the Biofreeze Roll On Pain Relieving Gel on it. R125 said she used the Biofreeze on her knees when she had pain. R125 said she puts the Biofreeze on, and she had put it on a few days ago. On 4/10/25 at 1:03 PM, V16 (Agency RN/Registered Nurse) said she did not have any residents…

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

Based on interview and record review, the facility failed to follow the physician's orders for obtaining a urinalysis in a timely manner. This applies to 1 of 3 residents (R1) reviewed for care delay. The findings include: R1's diagnoses included metabolic encephalopathy, unspecified fracture of the right pubis, muscle weakness, dementia, depression, scoliosis, and altered mental status. R1 was cognitively impaired per the MDS (MDS/Minimum Data Set), dated 04/04/24. The same MDS showed R1 was dependent upon staff for toileting. Per the EMR's (EMR/Electronic Medical Record) progress notes, dated 06/18/24, R1 had urine collected for urinalysis, and culture & sensitivity. R1's preliminary results were received on 06/19/24 and an oral antibiotic (Cefdinir) was started pending the final urine culture & sensitivity. Per the physician's order sheet, Cefdinir was discontinued on 06/21/24 and another oral antibiotic (Macrobid) was started. R1's final urine culture dated 06/21/24 showed Klebsiella pneumoniae ESBL. On 06/16/24, per the EMR (EMR/Electronic Medical Record) physician's orders, an…

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 ADLs (Activity of Daily Living) care to residents. This applies to 4 of 16 residents (R8, R9, R14 and R19) reviewed for ADL care. The findings include: 1. On 4/4/24 at 12:12 PM, R8 was in bed in his room watching TV. R8 had short beard on his face. R8 said he does not like his beard; he would like it shaved and staff has not assisted him with shaving. R8's Minimum Data Set (MDS) of 2/29/24 shows his cognition is intact and R8 needs partial to moderate assistance with hygiene. R8's care plan (initiated 2/26/24) shows R8 requires assistance with ADLs (bed mobility, transfers, dressing, walking, personal hygiene and toileting). 2. On 4/4/24 at 12:32 PM, R9 was sitting in her wheelchair in the dining room during lunch. R9 had several white hairs on her chin. R9 said she wants the facial hair off. She said staff used to take care of it, but they have not done it recently. The next day on 4/5/24 at 1:03 PM, R9 was in bed watching TV; the facial hair still noted on her chin. R9's MDS of 3/27/24 shows R9's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promptly answer resident call lights. This applies to 3 of 16 residents (R3, R6, R7) reviewed for call lights in a sample of 17. Findings include: 1. The admission Record documents R3 as a [AGE] year old admitted to the facility on [DATE], with diagnoses to include left femur fracture, anxiety, history of falls and diverticulosis. A Progress Note, dated 3/25/2024, documents R3 as alert and oriented and able to make needs known to staff. On 3/26/2024 at 10:12 AM, R3's call light was already activated. V7 (Nurse Manager) entered R3's room to respond to the call light, and R3 stated she needed assistance to the bathroom to have a bowel movement. V7 informed R3 she would notify her Certified Nursing Assistant (CNA) to assist her to the bathroom and left the room. At 10:13 AM, R3 stated her call light was on for approximately 10-15 minutes prior to V7 entering her room. R3 stated, I have issues with them answering my light. At 10:15 AM, V8…

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 food services in a manner that prevents food borne illness. This applies to all 166 residents that receive food services from the facility. Findings include: On 3/19/24 at 10:29 AM, the kitchen tour was conducted with V7 (Assistant Dietary Manager) On 3/19/24 at 10:33 AM, the dry storage was observed. A storage bin with contents identified as oatmeal by V7 was not labeled with contents and had a date of 3/8/24. V7 stated the bin should be labeled with the contents, in date and expiration date sot that staff are not serving outdated food items. An open box 25 LB (pounds) containing a clear plastic bag of instant food thickener was open to air. V7 stated the bag should have been sealed to protect it from contamination. V7 stated she had taken a food certification course. Items should be labeled with contents in date and expiration date. It is important so that we don't serve expired food items to residents. Using expired food 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 observation, interview, and record review, the facility failed to assess residents for self-administration of medications, and failed to obtain physician order for resident to self-administer medications and to have medications stored in resident rooms. This applies to 5 of 5 residents (R3, R10, R17, R123 and R388) reviewed for medications in a sample of 34. The findings include: 1. On 3/19/24 at 11:19 AM, there was bottle of Tums Calcium Carbonate 1000mg Antacid on R10's bedside dresser. On 3/21/24 at 1:05 PM, R10 said, The gas medicine is mine, I use it ever so often, once in a while, when I get heartburn. R10's current Physician Order Sheet (POS) was reviewed. R10 did not have an order for Tums Calcium Carbonate, to self-administer medications, or to have medications stored at the bedside. R10's care current care plan was reviewed; R10 was not care planned for self-administration of medication. 2. On 3/19/24 at 11:29 AM, there was tube of Sooth and Cool Antifungal cream Miconazole Nitrate 2% and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have call lights accessible to dependent residents. This applies to 4 of 4 residents (R8, R21, R77 and R147) reviewed for accommodation of needs in a sample of 34. The findings include: 1. R21's EMR (Electronic Medical Record) shows the following diagnoses of respiratory failure, asthma, weakness, unsteadiness on feet and need for assistance with personal care. R21's MDS (Minimum Data Set) of 1/15/24 shows R21's cognition is moderately impaired and needs partial to moderate assistance with toileting, shower and bathing. R21's care plan (initiated 7/15/22) shows R21 is at risk for falls with interventions to keep call light within reach when in bedroom or bathroom. On 3/19/24 at 12:20 PM, V28 (Agency CNA/Certified Nurse Assistant) was completing bed bath on R21. R21 requested for some ice water. V28 left the room to get the water. R21 had oxygen concentrator in the room, but did not have her oxygen on during care. After V28 left, R21…

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

Based on observation, interview, and record review, the facility failed to have thermometers and complete temperature logs for residents' personal refrigerators. They facility also failed to remove expired items, label food, and clean refrigerators. This applies to 5 of 5 residents (R1, R2, R53, R62, R94) reviewed for refrigerators in a sample of 34. The findings include: 1. On 3/19/24 at 10:55 AM, during initial tour, R62 was not in his room. Inside R62's fridge, there was no thermometer. Inside, there were also 2 sandwiches with no date as to when they were prepared. There was orange juice, cola, and drinks with electrolytes. The fridge and freezer had orange stains from drinks inside. 2. On 3/19/24 at 11:02 AM, inside R53's fridge, there was no thermometer. Inside there was cream cheese, milk, apple sauce, bars of chocolate, crackers, and a bag of slices of bread with mold, with a sell through date of 2/28/24. R53 was asked by surveyor if the facility staff is taking temperatures of his fridge and if he had any concerns with his fridge. R53 couldn't understand surveyor because…

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 two residents were free from physical restraints. This applies to 2 of 2 residents (R77, R86) reviewed for restraints in a sample of 34. The findings include: 1. R77's face sheet showed diagnoses including cerebral infarction, non-Hodgkin lymphoma, chronic kidney disease, polyneuropathy, type 2 diabetes mellitus, and history of falling. R77's MDS (Minimum Data Set), dated 3/4/24, showed R77 had severe cognitive impairment and was dependent on staff for all activities of daily living. R77's Restorative Side Rail/Other Devices Evaluation, dated 3/13/24, showed, Indicate the type of Side Rail used: 2 half rails. On 3/19/24 at 12:31 PM, R77's full length side rails were both up. On 3/20/24 at 2:29 PM, R77's full length side rails were both up. At 2:29 PM, V15 (CNA/Certified Nurse Assistant) entered R77's room to assist R77 with changing her gown. V15 lowered R77's left full length side rail, and removed R77's blankets and changed her…

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

Based on interview and record review, the facility failed to administer medications timely as per the physician's orders. This applies to 1 resident (R82) in a sample of 34 residents reviewed for medication pass timing. R82's MDS (Minimum Data Set), dated 2/14/24, shows her cognition is intact. R82's POS (Physician Order Sheet) shows order, dated 3/14/24: Maintain at all times: Strict contact isolation precautions due to an active infection (ESBL urine) single room. R82's Care Plan, dated 3/14/24, shows resident is on contact isolation precautions related to positive ESBL in urine. Interventions include provide antibiotic therapy per the physician's orders. On 3/19/24 at 3:27 PM, R82 said she had been at the facility for 5-6 weeks, and on 2 occasions, the staff did not bring her medications. R82 said the most recent occasion was on 3/15/24, when she was moved into an isolation room after being diagnosed with a contagious bladder infection. R82 said she arrived into her new room at 4pm on 3/15/24. R82 said around 6pm, she asked her CNA (Certified Nurse Assistant) to ask her nurse why…

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 adjust the mattress and bed frame so the exposed metal frame was not a hazard. This applies to 1 resident R63 reviewed for accidents hazards in a sample of 34. Findings include: R63 was admitted to the facility on [DATE], with diagnoses that include cord compression, weakness, dementia, cerebral ischemia, rhabdomyolysis, cervical disc degeneration, and abnormality of gait and mobility. R63's MDS (Minimum Data Set), dated 2/29/24, shows he is cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 1. R63 is staff dependent for transfers and requires partial / moderate staff assistance to reposition in the bed. R63's care plan for memory deficit, poor safety awareness and difficulty understanding others, dated 2/29/24, sets the goal of resident being free of any injury related to accidents with interventions that include keeping environment uncluttered and any potentially harmful items out of reach. On 3/19/24 at 12:34…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain resident nutritional status and monitor weights as ordered. These failures resulted in R33 experiencing a significant weight loss. This applies to 1 resident (R33) reviewed for weight loss in a sample of 34. The findings include: R33 was admitted originally admitted to the facility on [DATE]. R33 was readmitted on [DATE] per the Face Sheet. R33's MDS (Minimum Data Set), dated 03/13/24, showed no BIMS score for R33, but showed R33's cognitive skills for daily decision making were severely impaired. The same MDS showed R33 was dependent upon staff for most ADL's (Activities of Daily Living). The same MDS showed R33 received nutrition through a feeding tube. The facility's Weights and Vitals Summary showed R33 had a -10% change [comparison weight 10/15/23, 94.6 pounds, -10.1%, -9.6 pounds]. R33's recorded weight on 10/15/23 was 94.6 pounds. R33's recorded weight on 03/19/24 was 85 pounds. R33's enteral feed orders were flush Gtube…

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 evaluate for gradual dose reductions (GDR) for a resident receiving psychotropic medications. This applies to 1 of 1 resident (R68) reviewed for antipsychotic medications in a sample of 34. The findings include: R68's face sheet showed she was admitted to the facility on [DATE], with diagnoses including dementia and depression. R68's face sheet showed R68 was not being followed by a psychiatrist. R68's MDS (Minimum Data Set), dated 1/1/24, showed R68 had severe cognitive impairment, required substantial assistance from staff for eating, oral hygiene, toileting hygiene, upper body dressing, and personal hygiene, and was dependent on staff for shower/bathing, lower body dressing, and putting on/taking off footwear. R68's POS (Physician Order Sheet) showed R68 was prescribed Prozac 10 milligrams at bedtime for anti-depressant and trazadone hydrochloride 50 milligrams at bedtime for insomnia. On 3/21/24 at 3:01 PM, V2 (DON/Director of Nursing) said a GDR…

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

Based on observation, interview, and record review, the facility failed to administer medications in the appropriate form and as ordered per physician. There were 29 opportunities with 3 errors, resulting in a 10.34% error rate. This applies to 2 (R47 and R121) of the 5 residents observed in medication pass. 1. On 3/20/24 at 9:15 AM, V24 (Agency LPN/Licensed Practical Nurse) administered Norco 5/325 mg to R47. When V24 told R47 she was giving her Norco, R47 said, I already had Norco, didn't I? to which V24 replied, That was yesterday. V24 did not go check the computer to look at the doctor's order or see what time R47 last received Norco. R47 then swallowed the Norco pill. R47's POS (Physician Order Sheet) shows order: Norco oral tablet 5/325 mg give 1 tablet by mouth three times a day for pain. R47's MAR (Medication Administration Record) shows the Norco is scheduled at 6AM, 2PM, and 10PM. There is no dose scheduled when V24 administered Norco to R47. R47's POS does not show an order for PRN Norco. R47's MAR shows a PRN order, dated 8/4/23: May give pain medication Norco oral…

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 apply PPE (Personal Protective Equipment) and perform handwashing for a resident who was on contact isolation for C. Diff. (Clostridium Difficile). The facility also failed to This applies to 2 of 2 residents (R21, R147) reviewed for infection control in a sample of 34. The findings include: 1. R147's face sheet showed diagnoses including Parkinson's disease, muscle wasting, need for assistance with personal care, and a history of falling. R147's MDS (Minimum Data Set), dated 2/7/24, showed R147 had moderate cognitive impairment. R147 required moderate assistance for toileting hygiene and personal hygiene, substantial assistance for oral hygiene, and was dependent on staff for eating, shower/bathing, upper and lower body dressing, and putting on/taking off footwear. R147's POS (Physician Order Sheet) showed, Strict Contact Isolation (C.Diff). R147's care plan, dated 3/13/24, showed, Resident requires strict Contact Precautions related to: C. diff. with interventions including, Observe isolation precautions as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control guidelines provided by IDPH (Illinois Department of Public Health) after a resident tested positive for Legionnaire's Disease. The facility's policy for Legionnaire's Disease was also incorrect according to CDC (Centers for Disease Control and Prevention) guidelines. The facility also failed to ensure staff wore appropriate PPE (Personal Protective Equipment) in a COVID-19 positive resident's room. This applies to 2 of 4 residents (R3, R4) reviewed for infection control in the sample of 4. The findings include: 1. On March 14, 2024 at 10:36 AM, V24 (IDPH Environmental Health) said she had sent the facility an email on March 7, 2024 to notify them of a positive case of Legionnaire's Disease for a resident (R1) who had resided in the facility prior to hospitalization. V24 said the email included instruction for the facility to restrict all water use or install a 0.2-micron biological filter to the faucet in the room…

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

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. This applies to 3 of 4 residents (R1, R2, R3) reviewed for activity of daily living in the sample of 4. The findings include: 1). R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, cervical disc disorder, muscle wasting and atrophy, type 2 diabetes, and other symptoms and signs involving cognitive function and awareness. R1's MDS (Minimum Data Set), dated November 3, 2023, showed R1 had moderately impaired cognition and was shown to be independent with self-care prior to being hospitalized . R1 used a walker at home. R1 required substantial/maximal assistance with toilet use, showering/bathing, lower body dressing, putting on footwear, and needs partial/ moderate assistance with upper body dressing. R1's care plan, dated October 27, 2023, showed R1 was 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 follow to ensure resident ADL (Activities of Daily Living) needs were met for residents who require assistance for transferring, incontinence care, and positioning. This applies to 4 of 8 residents (R27, R44, R70, and R324) reviewed for activities of daily living (ADL) in a sample of 33. Findings include: 1. On 05/03/23 at 10:54 am, V9 (CNA-Certified Nursing Assistant) and V10 (CNA) applied a gait belt around R70's waist and lifted resident onto the bed holding onto the gait belt. R70's both arms were contracted and in splints. After perineal care was provided, V9 and V10 together lifted R70 from the bed holding onto the loops of R70's pants and transferred R70 to her wheelchair. On 5/3/23 at 11:15 AM, V9 stated she transferred R70 holding onto R70's pants so R70's pants don't slide down. V9 stated she usually transferred R70 using gait belt. V9 stated gait belts are used to ensure fall prevention. On 5/4/23 at 12:55 PM, V2 (DON-Director…

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 place calls light within residents reach. This applies to 3 residents (R74, R117 and R159) in a sample size of 33. 1. On May 3, 2023, at 3:54 pm, R117 was on his bed, awake and dressed. R117's call light was clipped to itself between the nightstand and the wall. R117 stated he would like to have his call light, and thought it would be provided to him. R117's MDS (Minimum Data Set), dated April 10, 2023, indicates resident requires staff supervision with ADLs (Activities of Daily Living). R117's EHR (Electronic Health Record) care plan includes Resident is at risk for altered cardiovascular function related to hypertension, coronary artery disease and hyperlipidemia. Resident requires supervision to limited assistance with ADLs. At risk for falls related to unsteadiness on feet with impaired mobility. Care plan interventions include to keep call light within reach when in bedroom or bathroom. 2. On May 3, 2023, at 3:52 pm, R74 was sleeping…

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, facility failed to ensure resident's pain was assessed and managed. This applies to 1 of 4 residents reviewed for pain in a sample of 33. Findings include: On 5/2/23 at 12:22 pm, V14 (Wound Care Nurse) was doing skin assessment and dressing change on R68. R68 complained of pain at 7/10. On 5/3/23 at 11:25 am, R68 complained of pain at 8/10. R68 stated nobody checked on him if he is in pain or not, and he was hurting. R68 states, They don't care. On 5/3/23 at 11:30 am, V11 (LPN-Licensed Practical Nurse) stated she gave pain medicine to R68 at 11:00 am, but did not sign it on the MAR (Medication Administration Record). On 5/4/23 at 12:55 pm, V2 (DON-Director of Nursing) stated the MAR must be signed when a nurse administers a medication to a resident, and this signature confirms the resident actually received the medication. R68's MAR, printed on 5/3/23 at 12:42 pm, showed Hydrocodone-Acetaminophen 5-325 1 tablet every 6 hours as needed for pain and 1 tab as needed prior to wound care. The MAR showed no signatures on 5/2/23 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.