Harmony Palos

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for preparing food under sanitary conditions by not using hand hygiene, when necessary, not sanitizing surfaces after cleaning them, not ensuring appliances were adequately dried or free of surface contamination after cleaning and before use, and not ensuring hair restraints were worn properly. This failure applies to all 96 residents in the facility. Findings include: Kitchen On 11/19/24 from 10:30 AM - 11:30 AM Observed while taking temperature of seasoned rice observed V28 (Cook) doff and don gloves without performing hand hygiene then prepare pureed taco meat, observed V27 (Food Service Director) and doff and don gloves while performing tasks in the food prep area without performing hand hygiene. Observed V29 (Night Cook) doff and don gloves while performing hand hygiene while performing tasks in the food prep area then handle clean dishware. Observed V28 doff and don gloves multiple times without performing hand hygiene while preparing and temping food, handling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow their policy and procedures for comprehensive care planning by not ensuring care plans, and personalized care planning interventions were implemented as needed based on grievances, resident's past medical history, and comprehensive assessments. This failure applies to four of four residents (R7, R16, R45, and R56) reviewed for care planning. Findings include: R7 is an [AGE] year-old male with a diagnoses history of Metabolic Encephalopathy, Right and Left Side Pain from Back to Legs, and restless leg syndrome who was admitted to the facility 07/23/2024. R7's admission hospital records dated 02/21/2024 documents he had a history of frequent falls, he was admitted to the hospital after a fall at home, he had previous hospital admissions related to falls in the last few years, he has severe lumbar spine fusion and complains of pain, per family member he has been having more frequent falls as of late, and can be transferred to…

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

Based on observation and interview the facility failed to follow their policy to ensure multidose vials of insulin were dated when vials were first accessed for two residents (R14 and R5) and failed to safely dispose of seven expired bottles of house stock medications. This failure has the potential to affect 38 residents residing on the second floor. Findings include: On 11/19/24, at 10:53 AM, Surveyor asked V8 Registered Nurse (RN) to review second floor low-end medication cart. Surveyor observed a previously accessed insulin pen of Toujeo Solostar (insulin) 300 unit/ml injection that showed an order date of 10/30/2024. Insulin pen was not dated when it was opened or dated for when to discard on the pen or the bag it was in. This insulin pen had an expiration date of 8/31/2026 and was for R5. V8 (RN) verified the pen had previously been accessed and that it did not have a date on the insulin pen of when it was accessed or when it should be discarded. Surveyor observed the following: 5 house stock medications bottles expired in the same medication cart: Oyster shell Calcium 500 mg…

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, interviews and record reviews, the facility failed to implement the use of personal protective equipment during provision of care on residents in isolation rooms; failed to change soiled gloves during ADL (activities of daily living) care; and failed to prevent contamination of urinary catheter and bag by keeping it off the floor for four (R15, R71, R101 and R112) of four residents in the sample of 46 reviewed for infection control. Findings include: R15 is an [AGE] year-old, male admitted in the facility on 10/22/24 with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; and Chronic Viral Hepatitis C. On 11/18/24 at 11:39 AM, V16 (Certified Nurse Assistant, CNA) was observed providing ADL care on R15. V16 was observed wearing the same pair of gloves when she started wiping R15's face, neck, upper back, lower back and when cleaning the genital area. She (V16) was also wearing the same pair of gloves…

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, interviews and record review, the facility failed to assess and evaluate a resident for self-administration of inhalers and eyedrops; and failed to obtain physician's order for eyedrops for one (R10) of one resident in the sample of 46 reviewed for medications. Findings include: R10 is an [AGE] year-old, male, admitted in the facility on 08/16/24 with diagnoses of Other Pulmonary Embolism Without Acute Cor Pulmonale; Chronic Obstructive Pulmonary Disease (COPD), Unspecified; Chronic Respiratory Failure with Hypoxia; and Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. MDS (Minimum Data Set) dated 08/19/24 Section C recorded R10 has BIMS (Brief Interview for Mental Status) score of 12 which means moderate impairment in cognition. On 11/18/24 at 10:09 AM, R10 was observed in room, in bed, watching television. A Combivent inhaler was observed placed on bedside table. R10 was asked if he is self-administering the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow their policies for restorative nursing program services by not ensuring a resident received the necessary treatment and services to prevent further decline in physical functioning for a resident with a contracture. This failure applies to one of one resident (R45) reviewed for rehab and therapy services. Findings include: Resident #45 R45 is a [AGE] year-old male with a diagnoses history of Partial Paralysis following a Stroke, Dementia, and History of Falling who was admitted to the facility 09/16/2024. On 11/18/24 at 11:00 AM Observed R45's left hand contracted. R45 stated, he cannot use his left hand. V33 (Family Member) stated, she was told the facility won't provide therapy services for R45 hand because his insurance won't cover it. V33 stated, R45 has multiple medical insurances, and she isn't sure why some form of therapy services isn't covered for him. R45's admission Restorative assessment dated [DATE] documents he is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to ensure medical records for one resident are complete and accurately documented by containing accurate and complete restorative assessments and interventions to address care plan needs. This affected one of three residents (R1) reviewed for medical records. The findings include: R1's diagnosis include, but are not limited to Vertebra Fracture, Cognitive Communication Deficit, Unspecified Symptoms and Signs Involving the Nervous System, History of Falling, Dementia, Depression, Anxiety, and Osteoarthritis. Incident report provided to IDPH states on [DATE] R1 complained of pain to the right shoulder. X-rays were obtained with findings of acute appearing clavicle fracture. R1 was sent for evaluation to the hospital on [DATE] and returned the same day to the facility. R1 was a hospice patient and died on [DATE]. On [DATE] at 12:48PM V2, Restorative CNA, said R1 was on a turning and repositioning program. V2 said R1 can turn but needed 2 person assistance…

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 pressure relieving interventions were in place and failed to ensure dressing changes were completed for a resident with pressure ulcers for 2 of 3 residents (R3, R4) reviewed for pressure ulcers in the sample of 12. The findings include: 1. R4's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, disorders of muscle, urinary tract infection, resistance to multiple antibiotics, hypertension, cerebral infarction, and pressure-induced deep tissue damage of sacral region, right ankle, right heel, and left heel. R4's facility assessment dated [DATE] showed R4 is cognitively impaired and requires substantial to maximum assistance from staff for most cares. R4's care plan initiated 3/1/24 showed, [R4] has pressure injuries to R (right) heel, L (left) heel, sacral, and R lateral ankle related to impaired mobility . Apply wound treatment as ordered by the physician . On 3/9/24 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 ensure enhanced foods were provided as ordered and weights were obtained as ordered for a resident with weight loss for 2 of 3 residents (R1, R2) reviewed for weight loss in the sample of 12. The findings include: 1.R2's computerized profile printed on 3/9/24 shows diagnosis to include aphasia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, congestive heart failure, morbid obesity, and atrial fibrillation. R2's Facility assessment dated [DATE] showed R2 was dependent on staff for hygiene, toileting, bathing, and dressing. This assessment showed R2 was incontinent of bowel and bladder, and dependent on staff for bed mobility. This assessment showed R2's weight was 267 pounds, and R2 had no identified weight loss. On 3/9/24 at 9:42AM, R2 was resting in bed with the head of her bed elevated. R2 had a water pitcher with straw on the right side of her bedside table. There were no other food or drink…

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 incontinence care in a manner to prevent cross-contamination for 1 of 3 residents (R2) reviewed for activities of daily living in the sample of 12. The findings include: R2's computerized profile printed on 3/9/24 shows diagnosis to include aphasia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, congestive heart failure, morbid obesity, and atrial fibrillation. R2's Facility assessment dated [DATE] showed R2 was dependent on staff for hygiene, toileting, bathing, and dressing. This assessment showed R2 was incontinent of bowel and bladder, and dependent on staff for bed mobility. On 3/9/24 at 1:23PM, V6 (Certified Nursing Assistant - CNA) removed R2's blankets and unfastened R2's incontinence brief. V6 rolled R2 over on her left side. R2 was incontinent of urine and stool. V6 tucked the soiled incontinence brief under R2 and used wipes to clean R2 of stool. V6 then applied petroleum jelly to…

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

Based on observation, interview and record review the facility failed to ensure call lights where within reach for four (R58, R62, R290, and R293) of six residents in a sample of 25 residents reviewed for call lights. Findings include: 1. On 9/5/2023 at 7:30 AM, R58 and R62 were observed in bed with R58's call light hanging off the side of the bed and R62's call light behind her mattress, out of reach for the residents. On 9/5/2023 at 7:35 AM, V14 (Nursing Assistant) said all call lights should be attached to the resident's chest. On 9/5/2023 at 1:50PM, V2 (Director of Nursing) said all call lights should be within reach of every resident. Physician order sheet dated 8/24/2020 indicates that R58 has a diagnosis of hemiplegia and hemiparesis' following cerebra infraction affecting left non-dominant side and functional quadriplegia. Care-plan update 8/28/20 indicates R58 At risk for falls due to impaired balance/poor coordination, potential medication side effects, unsteady gait, recent fall. Place call light within easy reach; clip call button to pt.'s gown. Physician order 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 ensure residents were receiving routine range of motion exercises to maintain or prevent further loss of range of motion. This failure affected 5 residents (R18, R22, R56, R13, and R76) of 5 reviewed for range of motion in a total sample of 25. Findings include: 1. On 9-05-23 at 9:45 AM R56 said she is not receiving therapy services and said she is doing exercises for her right arm by herself without assistance from restorative nurse or CNA. On 9-05-23 at 9:25 AM R18 said she is no longer receiving therapy (due to insurance) and the staff is not helping her with exercises. On 9-05-23 at 8:39 AM, R22 said he has not received restorative therapy and is not currently receiving therapy services. On 9-06-23 at 12:04 PM, V2 (DON) said the previous company did not have a restorative program in place. Range of motion was provided during ADLs (dressing and bathing) by CNAs. On 9-07-23 at 10:57 AM, V27 (Director of Therapy Services) said currently there is a…

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

Based on observation, interview and record review, the facility failed to protect and value the resident's private space for three of five residents (R290, R292, R293) observed for resident's rights in a sample of 25. Findings include: On 09/05/2023 between 7:31AM to 7:40AM during observation, V6 (Registered Nurse) was observed entering R290's, R293's and R292's room without knocking or asking permission to go inside the residents' rooms. On 09/06/2023 at 7:40AM, V6 said that she should knock on the door and ask permission to enter first before going inside the residents' rooms. R290's order review report dated 9/6/2023 indicated admission date of 08/21/2023 and diagnoses including unspecified psychosis and unspecified dementia. R292's order review report dated 9/6/2023 indicated admission date 09/01/2023 and diagnoses including depression. R293's order review report dated 9/6/2023 indicated admission date 08/04/2023 and diagnoses including other specified depressive episodes. Facility Documents: Policy Title: Privacy and Dignity Revised: 7/28/23 Policy Statement: It is the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor a resident assessed as a high fall risk from having an unwitnessed fall from his bed. This failure affected 1 of 4 residents (R27) reviewed for falls. The facility failed to follow the Fall Policy by not conducting fall investigations or determining the root cause of fall incidents. This failure affected 3 of 4 (R18, R22, R27) residents reviewed for falls. The facility failed to follow fall care plan interventions by not using 2 staff members to provide care to resident in bed which resulted in resident falling out of bed and sustaining skin tears. This failure affected 1 resident (R1) of 3 residents reviewed for falls in a total sample of 25. Findings include: 1. On 9-7-23 at 1:20 PM, V1 (Administrator) said a fall investigation is to determine the cause of the fall and to help put interventions in place to prevent re-occurrences. V2 (DON) said there was no documentation of root cause analysis for R18, R22, and R27. On 9-6-23 at 11:11 AM, V7…

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 specialized care needs according to professional standards for residents on oxygen therapy for three of three residents (R293, R292, R61) reviewed for oxygen in a sample of 25. Findings include: On 09/05/2023 between 7:33AM to 7:40AM during observation with V6 (Registered Nurse), R293's and R292's room/door did not have any sign or indication that R293 and R292 were on oxygen. Upon entrance, R293 and R292 were observed connected to oxygen concentrator via undated nasal cannula. At 8:15AM during observation with V7 (Assistant Director of Nursing), R61's room/door did not have any sign or indication that R61 was on oxygen. Upon entering, R61 was observed connected to oxygen concentrator via undated nasal cannula. On 09/05/2023 at 7:40AM, V6 stated that there should be sign by the door indicating resident is on oxygen and the oxygen cannula should be dated each time it is being changed. On 09/05/2023 at 8:15AM, V7 said that a sign by the door should indicate the resident is on oxygen and the nasal cannula…

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 its infection control policy on hand hygiene for one of six residents (R61) reviewed for infection control in a sample of 25 residents. Findings include: On 9/5/22 at 1:00PM, during medication administration for R61, V6 (Registered Nurse) was observed picking up a garbage can per R61's request to bring it closer to R61. V6 then proceeded to spike an IV (intravenous) bag without changing gloves or performing hand hygiene. On 9/6/23 at 135PM, V6 stated, I should have washed my hands to prevent cross contamination. On 9/6/23 at V2 (Director of Nursing) stated that hand hygiene should be performed after touching a dirty surface and before providing care to residents. On 9/7/23 at 1:30 PM, V11 (Infection Prevention) stated employees are expected to change gloves or perform hand hygiene after encountering a contaminated surface and before providing care to residents. A physician order sheet dated 8/8/2023 indicates R61 was admitted 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 interview and record review, the facility failed to follow the Abuse and Neglect Policy by not reporting a suspicious arm bruise for 1 of 3 residents (R27) reviewed for injury of unknown origin/abuse in a total sample of 25. Findings include: On 9-6-23 at 12:06 PM, V1 (Administrator) said she was not aware of concerns of unexplained bruising to R27's arms. V1 said she will report this concern to the state agency immediately. On 9-6-23 at 12:04 PM, V2 (DON) said he was not aware of concerns of unexplained bruising to R27's arms. V2 said after receiving a concern of injury of unknown origin, staff should report to abuse coordinator and they (abuse coordinator or designee) would report to state agency. On 9-6-23 at 11:11 AM, V7 (ADON) said family made concerns of unexplained bruises while R27 was at the hospital. V11 said she reported bruising to abuse coordinator (unsure of the date) and is not aware if abuse investigation started. R27's Progress Notes do not document concerns of unexplained bruising to R27's arms. State Reportable were reviewed and no concerns of unexplained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to follow their call light policy and provide adequate and reasonable accommodation of resident needs to four residents (R8, R11, R12, R13) of 4 residents reviewed for call lights response. This inaction from facility workers resulted in extended wait times to residents attempting to have their needs met. Failure to respond to call lights in a timely manner has the potential to affect all residents on the unit. Findings include: On 08/14/2023 at 09:30 AM, V2 (Assistant Administrator) provided facility census that indicated current census of 83 residents in house. On 08/15/2023, reviewed grievance/concern logs and noted the following: Concern/Response Form unsigned and dated 05/09/2023 indicated R11, expressed concern with call light response time. Follow-up action taken was, in-serviced staff on call light response times. R11's face sheet indicates she was admitted to facility on 04/27/2023 and discharged from facility to home on [DATE]. Concern/Response…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to adequately discharge on e resident (R4) by not properly completing their facility discharge procedure and ensuring medications were reconciled with the resident. This failure, by the discharging nurse, caused R4 to be discharged from the facility to home with another resident's medication. This failure affected one of two residents (R4 and R14) reviewed for policy and procedures. Findings include: On 08/14/2023 at 09:30 AM, V2 (Assistant Administrator) provided facility census that indicated current census of 83 residents in house. On 08/14/2023 at 11:37 AM, R4 informed surveyor during phone interview that she was discharged home with R14's medication card for simvastatin 40mg (milligram) tablet that had 22 pills left on the card. R4 then said that she was sent home with her medications but did not indicate that the discharging nurse provided her with a list of medications or that her medications were reconciled with her upon discharge. Reviewed…

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

Based on interviews and record review, the facility failed to provide assistance with activities of daily living (ADLs) for two residents (R5, R13) assessed to be dependent on staff for grooming and personal hygiene by: 1. failing to ensure R13 received personal hygiene care and was free from having dried feces found on his body, bed linens and medical leg brace on numerous occasions and 2. failing to ensure R5 received showers as scheduled twice weekly and/or documented any refusals. This failure affected two of three residents reviewed for activities of daily living. Findings include: 1. On 08/14/2023 at 09:30 AM, V2 (Assistant Administrator) provided facility census that indicated current census of 83 residents in house. On 08/15/2023, reviewed grievance/concern log and noted form dated 08/08/2023 with concern by V22 (Family Member) regarding R13 that indicated family arrived on a Saturday morning and found feces on the patient and bed and when family asked for help, they were told by the staff it's not my job. Form indicated, weekend staff are not helpful with patient care.…

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

Based on observation, interview, and record review the facility failed to keep the call lights in reach for four residents (R16, R24, R48, R75) of seven reviewed for accommodation of needs in the sample of 21. Findings include: On 5/24/22 at 11:08am, R48 was sitting on the foot of his bed on the left side. R48 said, I don't know where my call light is. I need to be changed. I keep peeing on myself. R48's call light was on the floor on the right side of his bed. R75's, (roommate of R48) call light was on the bedside table out of reach of R75. On 5/24/22 at 11:16am R16 and R24 call lights were out of reach behind the bedside table. R16 was calling out, I have to pee, I have to pee! On 5/24/22 at 11:26am V8 (RN-Registered Nurse) said, they (call lights) should be of them (residents). At 11:28am V26 (CNA-Certified Nursing Assistant) said, they (call lights) should be in reach. On 5/26/22 at 9:50am V2 (Director of Nursing) said, the call light should be on the person. A policy titled Call Light indicates, 6. Always position call light conveniently for use and within reach. A clip may be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. On 5/24/22 at 12:05 PM the cart for PPE (personal protective equipment) for R78, R79, and R131 do not contain any gloves. On 5/25/22 at 9:45 AM the cart for PPE for R131 does not contain any gloves. On 5/24/22 at 1:10 PM V14 (Central Supply Clerk) said, I stock the cart when I bring it up and the CNAs (Certified Nursing Assistants) are responsible to replace items from the clean utility room. On 5/25/22 at 10:00 AM V15 (Certified Nursing Assistant) said, I have put some gowns in them (PPE carts). I guess everybody should replace stuff. They didn't give it to us as a specific CNA duty. On 5/25/22 at 12:21 PM V2 (Director of Nursing) said, residents who have not completed the Covid vaccine are placed on droplet and contact precautions for ten days. R78, R79, and R131 are on droplet and contact precautions. There is no policy for stocking PPE carts. The Central Supply Clerk should restock the PPE carts during the day shift when she is here. The CNAs should restock the PPE on other shifts. The census for R79…

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

Based on observation, interview and record review, the facility failed to follow its policy by failing to provide catheter dignity bags to two residents R15 and R27 reviewed for catheters in a sample of 21 residents. Finding include: On 5/24/22 at 11:30am during facility tour on the 2nd floor, R15 and R27's catheter bags were observed hanging without a dignity bag facing the doorway. This allowed for visitors to be able to see the catheter while walking past the residents' rooms. Interview on 5/24/22 at 12:05pm with V2 (Director of Nursing) revealed that the facility has dignity bags and all catheter bags should be inside a dignity bag. Interview on 5/24/22 at 1:00pm with V8 (Registered Nurse) revealed that catheter bags should be inside a catheter dignity privacy bag. Facility policy titled Catheter Care: Indwelling Catheter with revision date of 4/2019 includes: purpose; To provide hygiene for patient with indwelling catheters. Catheter bags should be covered with a catheter dignity bag to preserve the dignity of the patient . Procedure: 16. Check that tubing is not kinked,…

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

Based on observation, interview and record review the facility failed to properly administer medications as per physician orders and in accordance with professional standards of clinical practice, for one of one resident (R17) in a sample of 21 reviewed for medication administration. Findings include: On 5/25/2022 at 10:25am R17 was observed asleep in bed with a cup of applesauce, a spoon and crushed powder placed on the bedside table. R17 said that's my medication the nurse leaves it there all the time. At 10:35am V11 (Registered Nurse-RN) said, that is R17's morning medication, R17 will not take his medication if you try and give it to him right away so I leave it and keep coming back encouraging R17 to take his medication. I think it's care planned that R17 will not take his medication, he is alert and oriented times three. At 10:55am V2 (Director of Nursing-RN) observed R17 medication at the bedside and said no medication should be left at the beside unless they have a physician order to self-medicate and its care planned. A Physician Order Sheet dated 5/25/2022 indicates 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 provide personal hygiene and grooming, including incontinence care to residents who need total care in a timely manner. This deficiency affects all three (R24, R57 and R60) residents in a sample of 21 reviewed for Activity of Daily Living (ADL) provided for dependent residents. Findings include: 1. R60 was admitted on [DATE] with diagnosis to include Dementia, Cerebrovascular Disease (CVA), Gastrostomy, and Failure to thrive. R60's care plan indicates he has an ADL self-care deficit. R60 needs assistance with daily hygiene, grooming, dressing, oral care and eating. R60 needs to be checked for incontinence frequently and staff assists in providing incontinence care as needed. R60 has bowel and urinary incontinence. On 5/24/22 at 12:15pm, V19 Family member approached the nursing station and complained to V4 LPN that R60 has not been cleaned since this morning and needs to be changed. V19 said that she does his morning care when she comes 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 treatment and care in accordance with professional standards and their care plan for residents' who have a Peripheral Inserted Central Catheter (PICC), severe contractures on upper and lower extremities and a venous stasis ulcer. This deficiency affects two (R24 and R57) of three residents reviewed for Quality of Care. Findings include: 1. R24 was admitted on [DATE] with diagnosis to include Cerebral Palsy, Cerebral infarction, Myasthenia Gravis, Epilepsy, Scoliosis, Fusion of spine lumbar region, Gastrostomy. R24's care plan indicated she has ADL self-care deficit. She has alteration in musculoskeletal status due to impaired mobility and contractures. R24 does not have treatment order/care for severe contractures on both upper and lower extremities. No interventions formulated and implemented for the severe flexion contractures of bilateral hands/wrist and bilateral eversion/outward rotation of feet. R24's Therapy communication…

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 designate a qualified Infection Preventionist (IP) who had completed a specialized training course to be responsible for the facility's Infection prevention and Control Program necessary for the Covid-19 survey protocol. This failure has the potential to affect all residents at the facility. Findings include: On 5/26/2022 at 1:30pm V1 (Administrator) said as of now we do not have an infection preventionist, that nurse will start on Monday with a certification. The director of nursing will be handling the infection control until the nurse arrives. On 5/27/2022 at 10:30am V2 (Director of Nursing-DON) said that he oversees the Infection Preventionist duties along with the respiratory therapist. On 5/27/2022 at 10:50am, job description for the Director of Nursing-DON dated 8/02, Revised 2/08, 01/16, 06/17 indicates: Leadership Fundamentals the DON will oversee the development of the nursing department structure and roles of each position and Clinical Systems: Partners with the medical director, infection preventionist and…

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

Based on observation, interview and record review the facility failed to provide a bed that is in safe operating condition to a resident. This deficiency affects one (R60) of three residents reviewed for bed safe operating condition. Findings include: On 5/24/22 at 12:13pm V19, Family member, approached the nursing station and complained to V4 LPN that R60's bed still not changed, and it was not operating well for the last 2 months. She said that she spoke with V2 DON and V14 Central Supply recently last Friday and they promised that they would change the bed yesterday, but it was not done. Observed long metal bar under the bed, mattress cover ripped. V4 tried to raise the bed but the bed was non-functional. On 5/24/22 at 12:37pm called V20, Maintenance Director, and showed bed of R60. V20 said that the long metal bar that fell from the bed is responsible for moving the bed up and down. V20 said the mattress vinyl covering was ripped. V19 said that it has been going on for the last 2 months and nothing was being done. V20 said that V14 only notified him last Friday that R60's bed…

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.