Nexus at Palos

Based on interview and record review the facility failed to ensure that a safe discharge and transfer, was provided and the resident receive the correct medication for one of one resident (R9) reviewed for discharge. Findings include:On 2/24/2025 at 4:20pm V22 said the facility called her cell phone and ask them to bring the medications back to the facility. V22 said, It was not my family's. We returned the medication. It was not used. On 2/25/2026 at 2:57pm V18 (Licensed Practical Nurse-LPN) said that on 11/23/2025 she discharged and educated V22 (Family of R9) on medications and that they expressed understanding. The family was discharged home with the medications. Then about an hour later V18 said she noticed R9 medications and immediately called the family and asked them to return with the medications and pick up the correct medications. The family expressed understanding and returned the medications and retrieved the correct ones. On 2/26/2026 at 11:41am V2 (Director of Nursing-DON) said, I expect the nurses to discharge resident's using the two nurse system to verify 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 follow physician order for Bilevel Positive Airway Pressure (Bipap) machine usage affecting one (R2) of three residents reviewed for physician orders. Findings include:On 2/26/26 at 11:55AM, V7 (Licensed Practical Nurse Unit Manager), stated she confirmed physician order for R2 Bipap machine. V7 said V7 was unsure if R2 received it.On 2/26/26 at 12:15PM, V2 (Director of Nursing) stated R2 did have a physician order for Bipap to be used at night. V2 indicated that on Medication Administration Record a 9 recorded indicates not given/not administered. R2 is a [AGE] year-old admitted to the facility on [DATE] with the following diagnosis in part but not limited to: Displaced comminuted fracture of shaft of right tibia, chronic obstructive pulmonary disease with acute exacerbation, unspecified asthma, hyperlipidemia, essential hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, dependence on supplemental oxygen, syncope 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 ensure facility's daily nurse staffing information form posted at the front desk. This failure has the potential to affect 164 residents receiving care in the facility. Findings include:On 2/25/26 at 11:00AM, Observed that no daily staffing post is available or visible in the front desk.On 2/25/26 at 11:30AM, V1 (Administrator) said daily staff posting should be in the receptionist area, staffing coordinator does it. If daily staff posting not found at receptionist area, then it has not been posted.On 2/25/26 at 12:45PM, V2 (Director of Nursing) said daily staff posting should be posted at the receptionist desk at main lobby daily.On 2/25/26 at 1:04PM, V1 said there is no facility policy for daily staff posting, but it is a requirement to have it daily. Facility unable to provide policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement fall care plan interventions for residents at risk of falls. This applies to 2 of 2 residents (R3 and R6) reviewed for fall in a sample of 9.The findings include:1. R3 is an [AGE] year-old female admitted on [DATE], with intact cognition as per the Minimum Data Set (MDS) dated [DATE].A review of the facility's provided fall log documented that R3 had a fall on 12/25/25.A review of R3's fall care plan includes interventions, including to keep bed in the lowest position and call light within reach.On 2/21/26 at 11:55 AM, R3 was observed on her elevated bed, all the way to the top, with the call light on the floor.On 2/21/26 at 12:00 PM, V9 (Licensed Practical Nurse / LPN) lowered the bed to the lowest position and brought the call light from the floor to the residents within reach.On 2/21/26 at 12:00 PM, V9 stated the bed should be in the lowest position to prevent injury, and the call light should be accessible to residents. 2.…

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 review, the facility failed to provide an inner canula to the tracheostomy for one resident (R6) during tracheostomy care. This failure affected one (R6) of three residents reviewed for tracheostomy care.Findings include:R6 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to cardiac arrest with anoxic brain injury, chronic respiratory failure with hypoxia, tracheostomy and gastrostomy tube, and heart failure. On the (MDS) Minimal Data Set assessment of section C on 01/18/2026, the BIMS (Brief Interviewed Mental Status) section C1000, Cognitive Skills for Daily Decision Making, shows R6 is severely impaired. MDS section GG of 1/18/2026 GG, R6 is dependent care - Helper does all the effort. Residents do none of the effort to complete the activity. The assistance of 2 or more helpers is required for the residents to complete the activity. R6's physician order dated 1/16/2026 reads in part, change inner 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.

Based on interview and record review, that facility failed to provide incontinence care for a resident who was identified as dependent on staff for toileting for over four hours. This affected one of three residents (R2) reviewed for incontinence care. Findings include:R2's minimal data set (MDS) section GG (functional abilities) dated 6/7/25 documents: toilet hygiene dependent. Section H (bladder and bowel) documents: always incontinent with urinary and bowel continence. Care plan dated 5/16/25 documents: Check R2 as required for incontinence.On 9/2/25 at 12:10pm, R2 was observed sitting in his wheelchair, urinating on the floor with his clothes on while attempting to eat his lunch tray. R2's jogging pants were observed with wet pants in between his legs.On 9/2/25 at 12:15pm, V8 (restorative) said, R2's jogging paints were wet in between his leg. V8 said, R2 was soiled and saturated with urine.On 9/2/25 at 1:05pm, V6 (CNA) said, she last provided incontinence care for R2 at 8am.On 9/2/25 at 3:04pm, V6 (CNA) said, resident are supposed to be changed every two hours.Incontinence Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to follow its abuse policy by having residents lose their bank cards and state IDs. This applies to 3 of 3 residents reviewed (R3, R4, and R2) for misappropriation of resident property in a sample of 9 residents.The Findings include: Findings include:1.R3 is a [AGE] year-old female admitted on [DATE] with cognition intact as per the MDS dated [DATE].On 8/6/25 at 3:00 PM, V1 (Administrator/Abuse Coordinator) stated, R3 came up with bed bugs, and we collected her belongings to freeze them. We found money (approximately $ 40) and a state ID. There were no bank cards. When we spoke with the power of attorney (POA), she said she doesn't want to get anything back and trash everything. The housekeeping might have trashed everything. We reimbursed her money, but we couldn't locate her state ID.A review of the nurse's note dated 7/10/25 documents that the family couldn't locate R3's purse, and the facility was made aware of R3's missing purse upon discharge.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 follow its Fall Prevention and Management Guidelines by not implementing fall prevention interventions in place for high-risk fall residents. This applies to 2 of 2 residents (R1 and R5) reviewed for fall. The findings include:1. R1 is a [AGE] year-old female admitted on [DATE] with severely impaired cognition as per MDS dated [DATE]. A review of the fall log indicates that R1 had a fall on 4/8/25 and 5/5/25 with no injury.The record review on fall risk assessment dated [DATE] documents that R1 is at high risk for falls. On 8/5/25 at 1:45 PM, R1 was observed in her bed with floor padding not in place. Surveyor instructed R1 to push the call light but R1 was unable to use the call light. V15 (Minimum Data Set/MDS Nurse) requested R1 to push the call light but R1 was unable to use the push button call light. On 8/5/25 at 1:47 PM, in response to the writer's request, V15 pushed the call light button, and it was not working. Observed V15 push…

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 discard expired intravenous fluid, house stock and resident specific medications; failed to ensure open date and expiration dates were labeled on multi-dose insulin and tuberculin vials; and failed to ensure residents medications were stored per policy in the medication room, medication cart and medication refrigerator. This affected four of four residents (R4, R74, R75, R452) reviewed for medication storage and labeling. Findings include: On 05/13/25 10:00 AM, the medication storage room on the long term west nursing unit was checked with V4 ADON (assistant director of nursing). There were (2) one liter bags of intravenous fluids, D5.45, that expired April 2025 and (1) 1 liter bag of intravenous fluids, D5, that expired January 2025. There was one intravenous catheter kit that expired on 5/1/25. The refrigerator contained: (1) small container of vanilla pudding that was not labeled or dated. (2) containers of applesauce that were not labeled or dated. (32) Dulcolax suppositories with an expiration date 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 interviews, observations, and records reviewed the facility failed to implement their policy for contact isolation precautions for residents with positive multidrug resistant organisms and failed to clean the Glucometer between resident use for blood sugar checks. This affected ten residents (R13, R52, R99, R123, R148, R152, R153, R48, R133, R154) in the total sample all reviewed for infection control practices in the sample. Findings include: On 5/13/25, R13, R99, R123, and R153 were observed to have contact isolation signs and an over-the-door hanging isolation container on their doors. On 5/13/25 at 3:45 PM, V19 CNA (certified nurse aide) was observed entering a contact isolation room. No hand hygiene was performed, or PPE (personal protective equipment) donned prior to entering R13's room with a non-disposable portable blood pressure machine and obtain R13's vital signs. A staff member was observed at R13's room and informed V19 to don PPE due to the State Surveying Agency staff were in the facility. V19 was observed exiting R13's room, no hand hygiene performed; V19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their change of condition policy by not immediately notifying the physician or nurse practitioner of a white patches in the mouth and on the tongue for one resident for two days. This affected for one of three (R352) residents reviewed for notification. Findings include: R352 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure, tracheostomy status, weakness and lack of coordination. R352 Minimum Data Set, dated [DATE] documents a brief interview for mental status score of 12/15 which indicate cognitively intact. Under oral hygiene documents R352 requires supervision or touching assistance which indicate helper provides verbal cues and or touching and or contact guard. On 5/13/25 at 12:20PM, Surveyor observed yellow mucous and raised white/ yellow patches on R352 tongue and roof of mouth. R352 said he has not had any oral care in two weeks. V7 (nurse) was made aware of concern during observation and confirmed…

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 the facility failed to refer a resident with serious mental illness for preadmission screening level 2 for two of two residents (R29 and R83) reviewed for appropriate PASRR screening. Findings include: 1. R29 face sheet shows diagnosis of anxiety, depression, schizophrenia, and bipolar, R29 MDS dated [DATE] section I for mood disorders shows diagnosis of anxiety, depression, schizophrenia, and bipolar. Section A1500 denotes is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No is checked. Request was made to review R29 PASRR level 2 assessment. During this survey the facility failed to provide a PASRR level 2 for R29. On 5/16/25 at 2:14pm V28 (social service) said R29 has diagnosis of serious mental illness, R29 should have been referred for a PASRR level 2. 2. R83 face sheet shows diagnosis of anxiety, and major depression, R83 MDS dated [DATE] section I for mood disorders…

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 05/13/25 at 11:21AM R148 said, I haven't' had a shower since before being in the hospital. I would really like a shower. I had my hair washed by the beauty shop, nearly 2 weeks ago. R148 looks oily and clumped together. R148 said, I would like a shower, I would not refuse one. V55, R148's son, present during interview and said she could be bathed or washed more or better. R148 cognition assessment dated [DATE] identifies a score of 15, cognitively intact. 5/15/25 at 11:47AM V56, CNA, was asked if she gave R148 a shower. R148 said, I don't really remember who she is, I don't work that side often. If they refuse a shower, we document it. I may have given a bed bath. We document bed bath or shower and give the shower sheet to the nurse. 5/15/25 11:51 am V57, CNA, said, We know who our shower is by the green binder. Showed the surveyor the binder. V57 said R148's showers are on Thursday and Saturday evenings. Shower sheets for R148 dated 4/24- 5/10 do not indicate a shower was given, not if a bed bath or…

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 plan of care for assistance with hygiene for a dependent resident. This affected one of three residents (R57) reviewed for activities of daily living for dependent residents. Findings Include: On 5/13/25 at 10:44am R57 was observed resting in bed, alert. R57 observed with long beard hair, unkept. R57 said the staff is always busy, so he has been shaved. R57 said he would like his beard shaved. R57 said he does not want his hair cut. R57 said he does not know when the last time he was shaved. R57 said his nails needs to be cut down also. R57 said they staff are too busy. R57 said he cannot shave himself. On 5/14/25 at 10:56am R57 observed with long beard hair, unshaved. On 5/15/25 at 10:30am R57 observed with long beard hair, unshaved, and nails observed long and unclean. 5/15/25 Vx (CNA) said she was R57 aide, and she didn't notice anything about R57 needing to be shaved. R57 care plan dated with initiated date of 11/15/2023 denotes in-part ADL (Activity of Daily living: R57 requires assist with daily care needs…

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

Based on observation, interview and record review, the facility failed to follow physician orders and provide a Bipap machine for 5 days for a resident diagnosed with obstructive sleep apnea, and chronic respiratory failure for one of one resident (R13) reviewed for following physician orders. Findings include: On 5/13/25 at 12:15pm R13 said the Nurse keeps telling her that the face mask is broken for her CPAP machine. R13 said she did not have her CPAP placed on her last night (5/12/25) before she went to bed. A gray face mask, connected to a clear tube, was observed on R13's nightstand. V6 was made aware that R13 said her CPAP machine was broken. During a follow up interview, V6 said she did not check to see if R13 machine was broken. At 3:10p during a tour of R13 room with V6 (Unit manager) to identify R13 CPAP machine, V6 looked in all the drawers, and on the nightstand in R13's room, there was no CPAP machine noted. V6 said she did not remove any machine from R13's room. V6 said she informed respiratory therapy that R13 said her CPAP machine was broken. V6 said she did not have…

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 safe home like environment and ensure that a power strip was not resting in the bed for one of one resident (R57), reviewed for safe home environment. Findings include: R57 face sheet shows diagnosis of hemiplegia and hemiparesis. 05/13/25 10:44 AM R57 observed resting in bed, a white power cord was observed resting in the bed, down towards the foot of the bed. R57 was not able to reach the power cord or any of the items that was plugged in the power strip. 5/13/25 at 10:50am V33 CNA said the power strip should not be in the bed. V33 identified the power strip was on (red light illuminating). V33 repositioned the power strip between the mattress and the wall. The power strip was still resting on the bed sheets. V33 identified that R57's hearing aides were also plugged in the power strip. On 5/15/25 at 2:04 pm R57's power strip was observed resting in the bed, down toward the foot of the bed. There were multiple items plugged into the power strip. The red light was illuminated on the power strip,…

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 administer medications in a timely manner and ensure a resident's linens were clean. These failures affect one of three (R8) residents reviewed for quality of care in total sample of eight residents. Findings include: R8 is a [AGE] year-old male. R8's diagnoses are but not limited to critical illness myopathy, type 2 diabetes with diabetic neuropathy, chronic obstructive pulmonary disease, dysphagia, weakness, hypothyroidism, polyneuropathy, atherosclerosis, chronic atrial fibrillation, peripheral vascular disease, end stage renal disease, presence of aortocoronary bypass graft, long term use of anticoagulants, and long-term use of insulin. R8's BIMS (Brief Interview for Mental Status) dated 3/23/2025, notes R8 is alert. R8 was admitted to the facility on [DATE]. R8's care plan notes R8 have potential for difficulty in breathing due to chronic obstructive pulmonary disorder and obstructive sleep apnea. R8 requires the use of statin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent skin breakdown for a resident that drools for 1 of 3 residents (R2) reviewed for quality of care in the sample of 5. The findings include: On 2/24/25 at 10:22 AM, V27 (R2's family member) said R1 on 1/18/25 was with the agency RT (Respiratory Therapist - V18). V27 said R1 had wounds to the left side of her neck and the center of her neck just (just below her tracheostomy tube). V27 said R2 drools a lot, and the staff must not have been keeping her dry enough. V27 said R2 can't move and is unable to remove the drool herself. V27 said the staff knows they must keep R2 dry, but they didn't do it and her skin opened up. V27 said she took pictures of the wounds and notified the facility staff. R2's Facesheet dated 2/24/25 showed diagnoses to include, but not limited to: demyelinating disease of the Central Nervous System, tracheostomy (airway opening in the neck), heart failure, surgical repair of an aortic dissection (2022), oxygen dependent,…

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 records reviewed the facility failed to follow their policy to answer resident call lights and provide assistance as soon as possible, including toileting and hygiene needs. This affected three (R8-R10) of three residents reviewed for call lights. This resulted in R8 waited 29 minutes after her request to be changed. The findings include: On 1/15/25 at 12:44 PM R8's call light was activated, lit and beeping. V4, Certified Nursing Assistant (CNA), was in the hall with meal trays, near R8's room. V4 then went to other side of the hall to continue with the meal trays. On 1/15/25 between 12:44 PM and 1:04 PM R9 said they take too long, referring to staff assisting her. R9 said, I use the call light for various things, they (staff) take a long time. On 1/15/25 between 12:44 PM and 1:04 PM R10 said staff take too long at night. R10 said, I call for help to use the bathroom or empty the bottle (urinal). The surveyor observed a clear bag with white linens on the floor of R10's…

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

Based on observations, interviews and records reviewed the facility failed to follow their transmission based isolation precautions and enhanced barrier precautions for one resident with a multidrug resistant organism by not wearing a gown while administering medication via gastric tube. This failure affected one of three (R4) residents reviewed for transmission based precautions. The findings include: R4's diagnosis include, but are not limited to, Encephalopathy, Moderate Protein - Calorie Malnutrition, Resistance to Multiple Antimicrobial Drugs (C. Auris), Gastrostomy Status, Need for Assistance with Personal Care, and Quadriplegia. On 1/14/25 at 11:22AM R4's door has hanging bin with gloves, mask, and eye shields, but no gowns. On 1/14/25 at 11:43AM V2, Licensed Practical Nurse (LPN), was standing outside R4's room preparing medications, not wearing a gown. There were no gowns on the door bin and a sign on the door read all staff to wear gown and gloves. V2 entered the room and the door remained open. V2 was not wearing a gown when V2 entered the room or coming out of 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.

Based on interview and record review, the facility failed to follow their abuse policy by not reporting one resident's (R1) final abuse investigation results within five days to the Illinois department of public health for one of three residents reviewed for abuse. Findings include: R1's initial abuse reportable dated 10/29/24 documents: R1 reported CNA hit him in the mouth with bed remote control when putting him back to bed. On 12/6/24 at 9:30AM, V1 (administrator) said they were unable to locate or provide documentation of R1's final abuse reportable being sent to the Illinois department of public health. On 12/5/24 at 4:06PM, V1(Administrator) said they need to send a final report to the Illinois department of public health within five working days. Facility abuse policy reviewed 9/2017 documents under final investigation report: The administrator or designee will review the report and a final written report of the results of the investigation will be forwarded to the Illinois department of public health within five working days of the reported incident.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their mechanical lift policy by not utilizing two staff member to transfer one resident (R1) with a mechanical lift. This failure resulted in R1 hitting his head on the mechanical lift causing facial swelling around right eye for one of three reviewed for transfers. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis affecting right side, lack of coordination, weakness, muscle weakness, anxiety, depressive disorder, contractures of right shoulder, left shoulder, right knee and left knee. R1's brief interview for mental status score dated 11/30/24 documents a score of 14/15 which indicates cognitively intact. R1's plan of care revision dated 12/11/23 documents under Activities of daily Living (ADL) R1 requires assist with daily care needs related to hemiplegia and hemiparesis affecting right dominant side. Resident is total assist of two staff members for transfers and toileting. Resident is…

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

Based on interviews and record reviews, the facility failed to follow its psychotropic medication policy and obtain informed consent from the resident and/or resident's family member prior to initiating a psychotropic medication. This failure affected one resident (R4) out of four reviewed for medications in a sample of 12. Findings include: On 12/5/24 at 9:51AM, V2 DON (director of nursing) stated that upon admission the nurse is expected to obtain information regarding any medication allergy, type of reaction, and level of severity of reaction (mild, moderate, or severe). V2 stated that the nurse is expected to notify physician of medication allergy and reaction. V2 stated that the outside pharmacy will flag a medication order and nurse will call physician to discuss, depending on severity. V2 stated that the medication allergy, reaction, and severity of reaction should be documented in the resident's progress notes by the physician and nurse. V2 stated R4's bupropion medication was prescribed from hospital stay on 10/4/24. V2 stated R4's allergy tab in R4's electronic 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.

Based on interviews and record reviews, the facility failed to follow its medication administration policy and notify the physician of a medication not available from the outside pharmacy, failed to obtain an alternative medication to prevent a resident from missing any scheduled medication dosages, and failed to accurately document the medication was not administered in the resident's MAR (medication administration record). This failure affected one resident (R4) out of four residents reviewed for accuracy of documentation in the resident's electronic medical record in a sample of 12. Findings include: On 12/5/24 at 9:51AM, V2 DON (director of nursing) reviewed R4's medical record. V2 stated tolvaptan was ordered 9/21-9/29 and 10/10-10/28. V2 stated if the medication was not here, the nurse should have called the outside pharmacy to check on when the medication will be delivered and request an urgent delivery. V2 stated this facility has a convenience box that contains some medications. V2 stated the nurse should check the convenience box to see if tolvaptan medication is stocked…

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 implement abuse prevention protocol by failure to investigate and report allegation of resident mental abuse by an employee. This deficiency affects one (R1) of three residents reviewed for Abuse Prevention Program. Findings include: On 10/8/24 at 11:08AM, V4, Family member, said that on 8/25/24, V7 Agency Nurse questioned R1's ethnicity/color stating that V7 did not know how R1 got his last name. On 10/8/24 at 1:22PM, V1 Administrator informed of Mental abuse complaint allegation of V4 that on 8/25/24, V7 Agency Nurse questioned R1's ethnicity/color stating V7 did not know how R1 got his last name. V1 said V4 presented these concerns when they had IDPH surveyor in the facility last 9/19/24. V1 said V4 presented copy of the concern/grievance form she claimed she gave to V14 Assistant Administrator last 8/27/24. V1 said she did the investigation and but did not complete an abuse investigation incident because V4 presented grievance/concern, not abuse…

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 administered medication in accordance with the written orders of the attending physician. The facility failed to complete a medication error incident report for an omitted antibiotics medication. This deficiency affects one (R1) of three residents reviewed for Administration of Medications. Findings include: On 10/8/24 at 11:08AM, V4 Family member said medications are not administered properly to R1. On 10/8/24 at 1:06PM, V6 Infection Coordinator said R1's had delayed in intravenous (IV) antibiotics treatment because of omitted IV antibiotics medications. V6 said she noted extra IV antibiotics of R1 in the medication room when she is doing her antibiotics audit. V6 questioned the floor nurses and found out R1's medications were not given on the weekend. V6 said she did medication error incident report and called R1's physician and V4 Family member. Review R1's MAR (medication administration record) with V6. V6 said marked code of 9 on the following…

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 follow sacrum treatment orders as prescribed, and failed to follow their plan of care for turning and repositioning and not placing an extra linen under residents. This affected one of three residents (R5) reviewed for pressure ulcer prevention. This failure resulted in R5 sitting a dialysis chair for over eight hours in pain, getting upset, feeling angry despite his request to be placed back in bed, this also resulted in R5 laying on a mechanical lift sling for over two hours. Findings Include: R5 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction, type II diabetes, acquired absence of left leg below the knee and right leg above the knee amputations. R5's Braden score dated 9/11/24 documents a score of 14 which indicates moderate risk for skin breakdown. R5's Minimum Data Set, dated [DATE] under section G roll left to right documents dependent. R5 progress notes dated 9/10/24 documents: R5 entered facility via…

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 prevent an incident of staff to resident abuse for a resident assessed to be at risk for abuse. This affected one of three residents (R4) reviewed for abuse. This failure resulted in V6 (certified aid) calling R4 a mother fcker and pushing R4 onto the bed and R4 bumping his head on the wall. Using a reasonable person concept, R4 would have felt scared, victimized, intimidated and unsafe. Findings Include: R4 was diagnosis with anxiety and depression. R4 care plan dated 2/16/24 documents: patient is at risk for abuse and neglect related to being in a skilled rehab facility. Minimal data set section C (cognitive patterns) dated 5/14/24 documents a score of eight which indicated moderately impaired. On 8/21/24 at 3:27 pm, V5 (CNA) said, the incident with V6 (CNA) and R4 started in the dining room. V6 wanted R4 to speak to R12 his new roommate. R4 would not. V6 became upset. V6 told R4, R12 spoke to him, and he did say anything. R4 replied, he didn't have to say anything. R4 was a peaceful resident who avoids confrontation.…

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 provided incontinence care for one resident(R9) who was identified as dependent on staff for toileting for more than 2 and half hours for one of three residents reviewed for incontinence care. Findings include: R9's was admitted on [DATE] with a diagnosis of multiple sclerosis, weakness, needed for assistance with personal care, neuromuscular dysfunction of bladder. R9's Minimum Data Set, dated [DATE] documents under brief interview for mental status documents a score of 15/15 which indicates cognitively intact. Under toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. documents dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity). Under urinary incontinence it documents a score of 3. A score of 3 indicates always…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow hospital discharge medication order and ensure that Temozolomide (TMZ, Chemotherapy Medication) was discontinued on 02/22/2023. This affects one resident of three residents (R7) reviewed for hospital discharge instructions. This failure resulted in R7 receiving 8 additional dosages of a chemotherapy (Temozolomide) medication. Findings Include: R7 was with diagnoses of but not limited to non-Hodgkin lymphoma, extra [NAME] and solid organ sites. admitted in the facility on 2/22/23. R7 has an order of Temozolomide 140mg by mouth one time a day along with Temozolomide (TMZ, Chemotherapy Medication) 180mg for a total of 320mg, with an order date of 2/22/23 and start date of 2/23/23. Medication Administration Record shows that R7 received Temozolomide 320mg on 2/23/23, 2/26/23, 2/27/23, 2/28/23, 3/1/23, 3/3/23, 3/4/23 and 3/5/23 for a total of 8 dosages. Hospital discharged record for hospital stay of 1/25/23 to 2/22/23. After visit shows R7 has 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 observations, interviews, and record reviews the facility failed to follow their policy and procedures for adequate housekeeping by not ensuring resident rooms and medical equipment were cleaned thoroughly and in a timely manner, not ensuring resident's rooms were free of clutter, not ensuring a resident's mattress was replaced when heavily soiled, and not ensuring a resident's meal tray was removed timely. This failure applied to six of seven residents (R1, R7, R11, R13, R14, and R21) reviewed for environment. Findings include: 1. R7 is a [AGE] year-old female with a diagnoses history of Partial Paralysis due to Stroke, Acute and Chronic, Respiratory Failure, Moderate Protein Calorie Malnutrition, Chronic Kidney Disease, and Trach Status who was admitted to the facility 07/13/2024. On 07/22/2024 at 11:11 AM V30 (Family Member) reported R7 only has mobility on her left side due to paralysis. Observed some items cluttered on R7's bedside table and on her nightstand near her bed. V30 and R7 informed 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 observations, interviews, and record reviews the facility failed to follow their policy and procedure for providing assistance with activities of daily living by not ensuring a resident's nails were cut, not ensuring resident's received timely incontinence care, not ensuring resident's call lights were answered timely and were always accessible, not ensuring resident's consistently received bathing or showers and are free of odors, and not ensuring a resident who is dependent on staff for assistance was cleaned, dressed, and gotten out of bed. This failure applies to seven of eight residents (R1, R6, R7, R8, R11, R13, and R14) reviewed for activities of daily living. Findings include: 1. R7 is a [AGE] year-old female with a diagnoses history of Partial Paralysis due to Stroke, Acute and Chronic, Respiratory Failure, Moderate Protein Calorie Malnutrition, Chronic Kidney Disease, and Trach Status who was admitted to the facility 07/13/2024. On 07/22/2024 at 11:11 AM V30 (Family Member) stated between 12AM…

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, interview, and record review the facility failed to perform hand hygiene between gloves changes, during wound care; failed to change PICC line dressing weekly; failed to change suction canister weekly; failed to date oxygen tubing; and failed to use personal protective equipment during care for a resident on contact isolation. This failure applied to three (R7, R15, and R16) out 10 residents observed for infection prevention and control. Findings include: R7 is a [AGE] year-old female admitted to the facility 7/12/24 with diagnoses including but not limited to respiratory failure with mucous plugging, recurrent aspiration pneumonia with tracheostomy, Cerebral infarction with the right sided hemiplegia/hemiparesis with G-Tube placement. On 07/22/24 at 10:30 Observed R7's PICC line dressing dated 07/05/24, Tracheostomy without a dressing, suction canister dated 07/13/24 and oxygen tubing not dated. R7 has an order for contact isolation for Candida Auris dated 07/12/24 without signage on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to follow their policy and procedure for ensuring residents are cared for with dignity by not communicating to residents while providing care and not replacing a resident's mattress that was visibly soiled and smelling of urine. This failure applied to two of five residents (R7 and R11) reviewed for dignity. Findings include: 1. R7 is a [AGE] year-old female with a diagnoses history of Partial Paralysis due to Stroke, Acute and Chronic, Respiratory Failure, Moderate Protein Calorie Malnutrition, Chronic Kidney Disease, and Trach Status who was admitted to the facility 07/13/2024. On 07/23/2024 at 8:19 AM Observed V34 (Certified Nursing Assistant) and V32 (Agency Nurse) enter R7's room. Observed V34 assist V32 with repositioning R7. Observed V32 adjust R7's trach, pillow, and gown, and reposition R7's call light without communicating what was being done while care was being provided. Observed V34 finish assisting V32 and leave without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to follow their policy and procedures for hydration by not ensuring fluid intake was consistently monitored for a resident with Stage Five Chronic Kidney Disease. This failure applies to one of three residents (R8) reviewed for hydration. Findings include: R8 is a [AGE] year-old female with a diagnoses history of Epilepsy, Severe Calorie Malnutrition, Dysphagia, Vascular Dementia, Cocaine Abuse, and chronic kidney disease who was admitted to the facility 04/17/2024 and discharged [DATE]. R8's nursing progress note dated 4/18/2024 documents an order was placed by the nurse practitioner for her to receive IV fluids. R8's nursing progress note dated 4/19/2024 documents writer was informed by the on-call team that a nurse will come out to the facility this morning to insert medical equipment for R8 to receive IV fluids for hydration. R8's Point of Care reports for Amount of Food Eaten and Fluid Intake from 04/17/2024 - 04/31/2024 documents Fluid Intake for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly document a change in resident condition, including vital signs taken and administration of PRN (as needed) blood pressure medication in the resident's medical record. This failure affected one resident (R2) of three residents reviewed for change in condition. Findings include: R2 is a [AGE] year-old female admitted to the facility on [DATE] with past medical history of: Anoxic brain damage not elsewhere classified, acute respiratory failure with hypoxia, type 2 diabetes with unspecified diabetic retinopathy without macular edema, cardiac arrest, cause unspecified, dependence on renal dialysis, end stage renal disease, pneumonia, encounter for attention to tracheostomy, etc. R2 was sent to the hospital on 4/30/2024 for abnormal vital signs. Progress note documented by V9 (LPN) marked as a late entry on 5/1/2024 states the following: patient blood pressure elevated, gave patient PRN hydralazine 25MG. rechecked patient in 30 min bp went down 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 observations, interviews, and record reviews, the facility failed to follow their policies and procedures for preparing food under sanitary conditions by not wearing hair restraints properly, not performing hand washing when required, and not storing food in clean containers. This failure has the potential to affect all 141 residents currently receiving food items from the facility kitchen. Findings include: Facility completed CMS Form 671 and documented current census as 141 residents. On 02/13/24 at 10:18 AM Observed V28 (Prep Cook) with hair exposed from the sides and back of his hairnet while preparing food. Observed V30 (Dietary Aide) walking through the kitchen with his hairnet covering only the top of his hair. Observed V27 (Dietary Manager) walking through the kitchen with hairs exposed from the back of her hairnet. Observed the flour and sugar bins with spatter on the boarder underneath the lead. V27 stated the bins are cleaned when they are refilled. V27 stated when spatter or spillage is observed on the bins, she would wipe them. On 02/14/24 at 10:57 AM Observed…

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 an environment was clean and free of pervasive odor of urine and failed to provide adequate housekeeping services. This failure affected six of six residents (R8, R17, R22, R37, R94 and R117) reviewed for environment and has the potential to affect all 47 residents currently in the 300 sections of the long-term care unit. Findings include: 02/13/24 at 10:10AM while conducting resident observation, a very strong urine odor was noted as soon as surveyor entered the 300 unit of the long-term care section of the facility. The hallways were noted to be very dirty with dried up spills noted all over the unit. 02/13/24 11:10 AM, R8 was observed in her room in bed, awake and alert and stated she has been at the facility for about 2 years, she came from the hospital. Resident's room was noted to be disorganized with lots of garbage all over the floor, residents floor mat was noted with some brownish stain, used tissue paper was noted by the bed. R8 was asked if staff comes to clean her room and she said,…

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 follow their policy and procedures for adequate staffing by not ensuring there are enough staff to meet the resident's needs. This failure applies to five (R136, R146, R213, R214, R215) of 40 residents reviewed for staffing and has the potential to affect all 141 residents currently in the facility. Findings include: Facility completed CMS Form 671 and documented current census as 141 residents. On 02/14/24 at 10:16 AM V34 stated there are not enough staff, and R136 has had to wait for assistance when pressing the call light. V34 stated R136 may have to wait for an hour or more. V34 stated last weekend there was one CNA (Certified Nursing Assistant) and one nurse and that was the nurse manager who had to stay over because they don't have adequate help. V34 stated passing trays takes precedence over all other care including incontinence and medications etc. On 02/13/24 at 10:56 AM R214 stated the facility needs more staff and she sometimes must wait half an hour to one hour for a response to her call light.…

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 follow their policy and procedures for infection control by not wearing PPE (Personal Protective Equipment) in isolation rooms as required, by not properly cleaning, storing, and dating respiratory care equipment, and by not practicing hand hygiene while preparing residents meal trays. This failure applied to nine (R22, R94, R102, R212, R213, R214, R219, R220, R221) of 40 residents reviewed for infection control and has the potential to affect all 141 residents currently in the facility. Findings include: Facility completed CMS Form 671 and documented current census as 141 residents. On 02/13/24 at 10:56 AM Observed R214's humidifier bottle on her oxygen machine and her oxygen cannula and tubing without a date indicating when they were last changed. Observed R214's Bipap breathing machine mask sitting on a table next to the Bipap machine base uncovered. In response to the surveyor asking R214 if her Bipap mask is usually sanitized and covered, R214 asked if it was supposed to be sanitized and covered. R214…

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 feeding assistance to a resident in a timely manner, which resulted in the resident attempting to feed themselves and spilling their lunch tray all over themselves and the bed. This failure applied to one of one (R362) resident reviewed for resident rights. Findings include: R362 is an [AGE] year old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R362 has multiple diagnoses including but not limited to the following: multiple fractures, severe protein calorie malnutrition, respiratory failure, adult failure to thrive, dysphagia, dementia, and Parkinson's disease. On 2/13/24 at 12:10PM, V22 (Certified Nursing Aide) was observed passing lunch trays. R362 was observed lying on back in bed with tray table over resident. Observed V22 set R362's lunch tray onto her tray table directly above residents lap. V22 said 'R362 is a feeder and I will come back and assist her once I am done…

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 a low air loss mattress upon admission for a resident with two community acquired pressure ulcers: unstageable to the sacrum and a deep tissue injury (DTI) to the left heel. This failure applied to one of one (R125) resident reviewed for pressure ulcers. Findings include: R125 is a [AGE] year-old male who recently admitted to the facility on [DATE] and continues to reside in the facility. R125 has multiple diagnoses including but not limited to the following: muscle wasting, type II DM, difficulty in walking, CHF, HTN, pneumonia, and UTI. On 2/13/24 at 10:40AM, R125 was interviewed regarding care in the facility. R125 said he has a wound on his backside and one on his left foot. R125 said he had been requesting a low air loss relieving mattress since he admitted but has not received one yet. This surveyor observed R125 to be laying on a regular mattress. On 2/15/24 at 12:25PM, R125 said, Yesterday (2/14/24) was the first time 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provide proper and timely incontinence care for dependent residents and failed to ensure staff follow facility incontinence care guideline and facility's Certified Nurse's Aide (CNA) job description while providing care to residents. This failure affected two (R462 and R37) of six residents reviewed for activities of daily living. Findings include: 1. R462 is a [AGE] year old female who was recently admitted to the facility on [DATE], with past medical history of traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration - subsequent encounter, adjustment disorder with anxiety, chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity, gastro-esophageal reflux disease without esophagitis, adjustment insomnia, hypertension, hyperlipidemia, unspecified, history of falling, displaced intertrochanteric fracture of left femur - subsequent encounter for closed fracture…

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 achieve a medication error rate below 5%. Medication error rate was 27.59% and affected one (R32) of four residents reviewed during medication administration task. Findings include: On 2/24/23 at 8:58AM, V13 LPN (Licensed Practical Nurse) was observed providing 9:00AM medication for R32. During this observation, eight medications were omitted which included: Imatinib 400mg Rifaximin 550mg, Lidoderm Patch 5%, Thiamine 100mg, lidocaine Cream 4%, Calcium 500+D 500- 200mg-unit, Lactulose Oral Solution 20GM/30ML- 30ml by mouth two times a day for elevated ammonia levels, Neurontin 100mg twice daily for neuropathy. At the time of this observation, V13 said they were agency and that these medications were not available in the medication cart at the time. V14 Nurse Practitioner for R32 was present and standing nearby at the nurse's station. V13 explained to V14 that the medication was missing. V14 said the medication Imatinib was especially important to reorder from the pharmacy because it is used to treat cancer.…

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 review the facility failed to implement the plan of care with interventions to reduce and/or prevent the risk of falling to include placing non-skid socks or shoes on one resident This failure affected one (R5) of three residents reviewed. The findings include: R5's diagnosis includes but not limited to Weakness, Unsteadiness on Feet, Psychosis, Depressive Disorder, and Atrial Fibrillation. On 9/12/23 at 10:28AM during unit tour the surveyor observed R5 in a wheelchair, sitting in the hallway outside of his room, feet swollen and no shoes, socks, or antiskid socks on. On 9/13/23 at 2:03PM V13, Licensed Practical Nurse (LPN), said, R5 always refuses to wear skid socks. V13 said I did not see the fall; it was reported to me. V13 said R5 is supposed to use the call light for assistance, we are supposed to check on him frequently. V13 said R5 is continent and takes himself to the bathroom. On 9/14/23 at 1:05PM V16, CNA, said I saw R5 fall from his chair and slide to 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 observations, interviews, and record reviews the facility failed to follow their policy and procedures for assistance with activities of daily living by not ensuring call light response is timely, not repositioning dependent residents as required, and not ensuring a dependent resident was showered as needed. This failure applied to four of four residents (R6, R7, R14, and R18) reviewed for activities of daily living. Findings include: 1. R6 is a [AGE] year-old female with a diagnoses history of Bladder related Cancer, Severe Protein Calorie Malnutrition, Adult Failure to Thrive, Cachexia, Anorexia, Weakness, Peripheral Autonomic Neuropathy, Schizoaffective Disorder, Anxiety Disorder, Major Depressive Disorder, and COVID 19 (02/27/2023) who was admitted to the facility 11/14/2022. On 08/07/2023 from 12:23 PM - 12:35 PM R6 stated sometimes she must wait an hour or two for a call light response. 2. R7 is a [AGE] year-old male with a diagnoses history of Bacteremia (07/23/2023), Chest Pain (07/23/2023),…

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 ensure a resident received her seizure and urinary tract infection medications as ordered. This failure applied to one (R18) of three residents reviewed for medication administration. Findings include: R18 is a [AGE] year-old female with a diagnoses history of Multiple Sclerosis, Neuromuscular Dysfunction of Bladder, Contracture of Right and Left Ankle's, Epilepsy, Functional Quadriplegia, Recurrent Major Depressive Disorder, and History of Urinary Tract Infections who was admitted to the facility 04/08/2015. On 08/15/2023 from 9:46 AM - 10:07 AM R19 (Family Member) stated many times the facility doesn't have R18's seizure medication and as a result R18 has ended up in the hospital. R19 stated R18 needs her seizure medication. R18's Current care plan documents she is at risk for seizure activity related to a diagnosis of Epilepsy with interventions including Medication as ordered. R18's May 2023 Medication Administration Record documents four missed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedures for reporting abuse allegations by not reporting an allegation of abuse provided by a resident's representative to the state agency. This failure applied to one (R18) of three residents reviewed for abuse. Findings include: R18 is a [AGE] year-old female with a diagnoses history of Multiple Sclerosis, Neuromuscular Dysfunction of Bladder, Contracture of Right and Left Ankle's, Epilepsy, Functional Quadriplegia, Recurrent Major Depressive Disorder, and History of Urinary Tract Infections who was admitted to the facility 04/08/2015. On 08/16/2023 at 12:41 PM V30 (Family Member) stated when V30 expressed concerns regarding threatening behavior of V32 (Certified Nursing Assistant) towards R18 and R19, V30 was told by facility V32 would be moved to another unit which caused V30 to think, so she (V32) can continue to do this to other people? V30 stated he reported to V1 (Administrator) around 08/08/2023 that R19 reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedures for reporting abuse allegations by not reporting an allegation of abuse provided by a resident's representative to the state agency. This failure applied to one (R18) of three residents reviewed for abuse. Findings include: R18 is a [AGE] year-old female with a diagnoses history of Multiple Sclerosis, Neuromuscular Dysfunction of Bladder, Contracture of Right and Left Ankle's, Epilepsy, Functional Quadriplegia, Recurrent Major Depressive Disorder, and History of Urinary Tract Infections who was admitted to the facility 04/08/2015. On 08/16/2023 at 12:41 PM V30 (Family Member) stated when V30 expressed concerns regarding threatening behavior of V32 (Certified Nursing Assistant) towards R18 and R19, V30 was told by facility V32 would be moved to another unit which caused V30 to think, so she (V32) can continue to do this to other people? V30 stated he reported to V1 (Administrator) around 08/08/2023 that R19 reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedures for investigating abuse allegations by not formally investigating an allegation of abuse provided by a resident's representative. This failure applied to one (R18) of three residents reviewed for abuse. Findings include: R18 is a [AGE] year-old female with a diagnoses history of Multiple Sclerosis, Neuromuscular Dysfunction of Bladder, Contracture of Right and Left Ankle's, Epilepsy, Functional Quadriplegia, Recurrent Major Depressive Disorder, and History of Urinary Tract Infections who was admitted to the facility 04/08/2015. On 08/16/2023 at 12:41 PM V30 (Family Member) stated when V30 expressed concerns regarding threatening behavior of V32 (Certified Nursing Assistant) towards R18 and R19, V30 was told by facility V32 would be moved to another unit which caused V30 to think, so she (V32) can continue to do this to other people? V30 stated he reported to V1 (Administrator) around 08/08/2023 that R19 reported V32…

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

Based on interview and record review, the facility failed to follow their policy and procedure to ensure the call light was answered in a timely manner for 9 of 147 residents (R2, R18, R75, R77, R85, R97, R371, R379, R380) in the facility. Findings Include: On 10/31/22 at 11:00am, R371 was interviewed and said it takes the staff a very long time to respond to his call light. On 10/31/22 at 11:32 AM, R379 was interviewed and said it sometimes takes 20-25 minutes for staff to respond to call lights because they are short staffed. On 10/31/22 at 1:42 PM, R380 stated he has had to wait for someone to respond to his call light for 2-2.5 hours. One time he had to wait this long with poop in his pants to be changed. R380 stated he must wait long periods of time because they're understaffed. On 11/01/22 11:21 AM, V22 (Agency Certified Nursing Assistant - CNA) stated a CNA that had been working since 2 pm yesterday to 7 am this morning wouldn't respond to a female resident's call light. This same CNA said she was not going to deal with that lady because her call light has been on all night.…

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 review, the facility failed to label insulin pens with the date open and the expiration day, failed to refrigerate insulin and/or injectable medications upon the receipt from the pharmacy, failed to accurately reconcile controlled substance, failed to keep external medications in a treatment cart or in a separate drawer, failed to removal outdated medication from refrigerated medication storage and failed to prevent the maintenance of unlabeled/unknown medication in a cup within the medication cart; which prohibited the facilitation of safe precautions and safe administration of these drug and biological medications. This applies to 10 of 32 residents (R20, R39, R108, R113, R121, R122, R123, R124, R125, R220) residents reviewed for medication storage and labeling during the inspection the of the first and second floor medication room & cart. Findings include: 1. On [DATE] at 11:06 AM, surveyor entered second floor med storage room with V30 (Registered Nurse). V30…

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.