Accolade Hc Of Paxton On Pells

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have a qualified Infection Preventionist with the required training in infection prevention and control. This failure has the potential to affect all 92 residents in the facility. Findings include: The facility's Facility assessment dated [DATE] documents the facility will have an Infection Control Preventionist as part of its staffing plan. On 1/14/25 at 10:48 AM V1 Administrator stated V9 Wound Nurse/Infection Preventionist was recently hired as the Infection Preventionist for the facility with the intention of V9 completing the Infection Prevention training course. V1 stated nurse managers and V1 have collectively been overseeing the Infection Preventionist role prior to V9 being hired. On 1/15/25 at 1:33 PM V1 confirmed V1 does not have completed infection prevention training to provide for any of the nurse managers who are involved in the infection control program. On 1/15/25 at 9:05 AM V9 stated V9 has not officially taken over as the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for four of four residents (R39, R17, R25 and R52) reviewed for hospitalizations on the sample list of 38. Findings Include: 1. R39's ongoing Census documents R39 was hospitalized from [DATE] - 7/24/24 and 12/30/24 - 1/2/25. R39's medical record does not contain a copy of the facility Bed Hold Policy. On 01/14/25 at 8:40 AM, R39 stated R39 went to the hospital recently but unsure of the exact date. R39 stated the facility did not talk with him about a Bed Hold Policy. On 1/14/25 at 12:21 pm, V2 DON (Director of Nursing) stated Bed Holds are to be filled out by the nurses when a resident is sent to the hospital; a copy is sent with the resident, and we keep a copy. On 1/14/25 at 12:55 pm, V2 DON stated after talking with the nurses, they are no longer doing the Bed Holds at the time of hospitalization and also stated nothing is being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain privacy during wound care for one (R70) of 24 residents reviewed for privacy in the sample of 38. Findings include: R70's Minimum Data Set, dated [DATE] documents R70 has severe cognitive impairment. On 1/14/25 between 12:10 PM and 12:52 PM V9 Wound Nurse, V18 Wound Nurse Practitioner, and V40 Certified Nursing Assistant (CNA) performed R70's wound assessments and treatments. V9 and V40 entered and exited R70's room during R70's wound care. The privacy curtain wasn't pulled to block the view from R70's doorway and hallway while R70's buttocks/perineal area was exposed. On 1/15/25 at 9:05 AM V9 confirmed R70's privacy curtain should have been pulled during R70's wound care to block the view from the doorway and hallway. On 1/15/25 at 10:30 AM V2 Director of Nursing entered R70's room to observe R70's wounds. V2 did not pull the privacy curtain to block the view from the hallway and R70's doorway. V31 CNA entered and exited R70's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to offer services to maintain or increase range of motion for one of three residents (R34) reviewed for range of motion in the sample list of 38. Findings include: On 1/13/25 at 9:04 AM R34 was sitting in a wheelchair in R34's room and there was a brace on R34's right leg. R34 stated R34 is unable to walk and unable to move R34's right arm and leg, and R34 has not received any therapy services or exercise programs since R34 admitted to the facility. On 1/13/25 at 3:41 PM V15 MDS (Minimum Data Set) Coordinator stated the facility doesn't have restorative nursing services where participation is recorded, but they have walk to dine programs. At 3:48 PM V15 stated R34 has not yet been evaluated by therapy since R34 transferred from another facility where therapy had just been completed. On 1/14/25 at 3:47 PM V2 Director of Nursing stated V2 just became aware yesterday that skilled nursing facilities (SNF) are supposed to offer restorative nursing…

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 investigate and record a fall incident and failed to complete fall risk assessments for one of one resident (R39) reviewed for falls on the sample list of 38. Findings include: On 01/14/25 at 08:40 AM R39 reported slipping out of his wheelchair when R39 was in transport van because the full mechanical lift sling was under R39 and caused R39 to slip down in R39's wheelchair. R39 explained that R39 did not completely hit the van floor but rather slipped to the edge of the chair and R39's legs were holding R39 up because R39's legs were pinned against the seat in front of R39. R39 stated R39 did not hit the floor. On 01/16/25 at 09:09 AM V2 (DON) provided an electronic mail from V29, transporter, dated Tuesday, December 31, 2024, at 6:42 AM. V29's email to V2 explained that on December 30th, 2024, V29 was transporting R39. V29 stated that within blocks of the destination, R39 stated that he was sliding out of R39's chair a bit. V29 explained that on arrival at the location, R39 was now midway between R39's wheelchair and the…

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

Based on observation, interview and record review, the facility failed to perform hand hygiene before and after catheter care to prevent potential contamination and failed to ensure a urinary drainage bag was covered with a dignity bag for one of one resident (R39) reviewed for catheters on the sample list of 38. Findings Include: On 1/13/25 at 8:40 am and 3:12 PM, R39 was lying in bed and had an uncovered urinary catheter drainage bag hanging on the bed frame, which was visible from the hallway. On 1/14/25 at 8:40 am, R39 was lying in bed and had an uncovered urinary catheter drainage bag hanging on the bed frame, which was visible from the hallway. On 1/15/25 at 11:25 AM, R39 was lying in bed and the urinary catheter drainage bag was hanging on the bed frame, covered in a dignity bag. At this time, V33 and V34 CNAs (Certified Nursing Assistants) both stated that catheter drainage bags should be in a dignity bag at all times. V33 and V34 donned gloves to provide catheter care using disposable wash rags but did not wash their hands before donning gloves. After catheter care was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain a re-admission weight, notify the physician and resident representative of significant weight loss, and develop a plan of care to address significant weight loss for one of three residents (R77) reviewed for weight loss on the sample list of 38. Findings Include: The facility's Weight Management policy dated August 2017 documents all residents will be weighed on admission, re-admission, and weekly for the first four weeks, then monthly thereafter. Weekly weights will also be done with a significant change of condition. Any significant weight loss will be reviewed with the physician to obtain an order for a nutritional supplement until the resident's condition is discussed during weekly risk meetings. The resident's care plan will be updated to include interventions promoting weight gain or loss. The family or Power of Attorney will be notified of significant weight changes and plan of care which will be documented in the resident's 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 observation, interview, and record review the facility failed to maintain hygienic care and storage of continuous positive airway pressure (CPAP) masks and oxygen nasal cannulas, and failed to develop a care plan for respiratory care and diagnosis for two of three residents (R57, R34) reviewed for oxygen in the sample list of 38. Findings include: 1.) On 1/13/25 at 9:17 AM R57's CPAP mask was uncovered and on top of the CPAP machine on R57's night stand. On 1/13/25 at 3:31 PM V14 Licensed Practical Nurse (LPN) stated CPAP masks are cleaned daily and confirmed the masks should be stored in a bag when not in use. V14 entered R57's room and confirmed R57's CPAP mask was uncovered and on top of the CPAP machine on R57's night stand. V14 stated V14 will need to get a bag to store the CPAP mask in. V14 stated R57 uses the CPAP at night, but sometimes removes it himself during the night. On 1/15/25 at 8:50 AM V2 Director of Nursing stated CPAP masks are cleaned daily per manufacturer's guidelines, placed on a towel in the bathroom to dry, and then should be stored in a plastic bag…

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 ensure that as needed psychotropic medication was limited to 14 days for one of five residents (R49) reviewed for unnecessary medications on the sample list of 38. Findings include: R49's November 2024 - January 2025 MAR (Medication Administration Record) documents R49 was started on Lorazepam {Antianxiety} 2 mg (milligrams) per 1 ml (milliliter) - give 0.25 ml every 4 hours as needed for agitation/restlessness which was ordered on 11/14/2024 {greater than 14 days ago}. These MAR's also document that R49 has not used this PRN (as needed) medication since 11/18/2024. On 1/15/25 at 1:39 PM, V2, Director of Nursing (DON) stated that PRN (as needed) orders which are for psychotropic medications are limited to 14 days. The facilities Psychotropic Medications Protocol dated January of 2024 documents when a PRN psychotropic mediation is ordered, it will have a 14 day stop date and the resident will be reassessed by the physician for further use. The protocol lists psychotropic medications as any medication that is used for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately report an allegation of potential sexual abuse to the Abuse Coordinator and to the State Surveying Agency. This failure has the potential to affect two of three residents (R1, R2) reviewed for abuse in the sample of three. Findings Include: The untitled facility investigation dated 8/28/24 documents in the morning meeting on 8/28/24 at approximately 10:15 AM it was mentioned that R2 was found in R1's bed the night before. V1 Administrator had not been made aware of the incident until that moment. An investigation began and staff were interviewed. V4 Certified Nursing Assistant (CNA) stated she worked the evening before (8/27/24) and witnessed R2 on top of the covers in R1's bed kissing R1 on the cheek. V4 stated she called down the hall for V5 Licensed Practical Nurse (LPN) to come and assist. V5 LPN stated V4 called for her to come and help because R2 was in R1's bed. Neither V4 nor V5 reported the incident to V1 Administrator/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.

Based on interview and record review the facility failed to re-evaluate and coordinate discharge plans to address the needs of a resident (R1) being discharged home and notify the physician of changes in the discharge plan for one of three residents reviewed for discharge in the sample list of six. Findings include: R1's Physician Order dated 3/5/24 given by V16 Nurse Practitioner documents okay to discharge home with home health pt/ot (physical and occupational therapy). R1's Wound Evaluation & Management Summary dated 3/6/24 and recorded by V20 Wound Physician documents R1's right heel stage three pressure ulcer measured 0.4 centimeters (cm) long by 0.3 cm wide by 0.01 cm deep, had moderate serous drainage, and was 100% subcutaneous tissue. This note documents R1's left heel stage three pressure ulcer measured 1 cm by 3 cm by 0.2 cm, had moderate serous drainage, had 10% thick necrotic (dead) tissue, and 80% subcutaneous tissue. The treatment orders were calcium alginate covered with a foam dressing three times weekly and to wear pressure relieving boots when in bed. R1's Post…

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 conduct and thoroughly document weekly skin assessments, identify a newly reopened pressure ulcer, notify the physician, and obtain pressure ulcer treatment orders for one (R4) of three residents reviewed for pressure ulcers in the sample list of six. Findings include: On 4/30/24 at 9:25 AM R4 stated R4 has two buttock wounds that developed in the facility. R4's Minimum Data Set, dated [DATE] documents R4 is cognitively intact, R4 is at risk for pressure ulcers, has one stage two pressure ulcer and two stage three pressure ulcers that were facility acquired. There are no documented weekly skin assessments in R4's medical record after 2/25/24 until 3/22/24, and then not again until 4/5/24. R4's Nursing Note dated 04/17/2024 at 3:02 PM documents R4 was evaluated by V20 Wound Physician and R4's left buttock wound is healed. R4's Nurses Weekly Skin assessment dated [DATE] documents no new skin issues but does not identify if R4 has a wound 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 observation, interview, and record review the facility failed to post staffing data which included staffing hours and the facility census. This failure has the potential to affect all 90 residents residing in the facility. Findings include: On 3/21/24 at 11:20 AM, a picture frame containing a daily assignment sheet dated 3/20/24 was sitting on the receptionist's desk at the lobby's entrance. This daily assignment sheet did not include the total number of hours for staffing or the resident census number. V34, Receptionist who was sitting at the desk, stated that is what the facility posts for daily staffing. When asked if this sheet included the total number of staffing hours and the number of residents, V34 stated no. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 3/18/24 documents a census of 90 residents.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 90 residents in the facility. Findings include: On 3/18/2024 at 10:02AM, V3 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V3 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V3 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V3 also denied being a certified Food Protection Manager, as required, for every person in charge of a food service. V3 reported the food in the kitchen is available for all residents to eat. V3 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality;…

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

Based on observation, interview, and record review, the facility failed to have necessary sanitation test equipment and failed to effectively sanitize dishes. These failures have the potential to affect all 90 residents in the facility. Findings include: On 3/18/2024 at 10:02AM, V4 (Cook) was washing and sanitizing dishes in the kitchen three-basin sink. The sanitizer solution in the sink basin tested 100 parts per million (ppm) by Illinois Department of Public Health (IDPH) sanitizer chemical test strip. V3 (Dietary Manager) was present and observed the test strip and agreed the solution tested 100ppm. On 3/18/2024 at 11:30AM, the above three-basin sink remained in use with dishes present in the sink. The sanitizer solution concentration again tested 100ppm with the State Agency test strip. V3 directly observed the test strip and agreed the strip measured 100ppm. V3 denied the kitchen had any sanitizer test strips for staff to verify the correct concentration of sanitizer solution was prepared to effectively sanitize dishes. A direction sheet was posted on the wall immediately…

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 comfortable environment by failing to provide warm showers. This failure has the potential to affect all 90 residents residing in the facility. Findings include: On 3/18/24 at 10:08 AM, R76 stated one of her main complaints is getting cold showers. R76 stated the water doesn't stay hot for very long. R76 stated the water will be warm at first and then all of a sudden it will turn cold before her shower is finished. On 3/20/24 at 9:15 AM, V33 Shower Aide walked out of the shower room. V6 Certified Nurse's Assistant walked over to where V33 was standing. V33 and V6 stated they work as the shower aides for the facility. V6 stated they do get complaints about the water getting cold during the showers. V6 stated on Monday (3/18/24) the residents were complaining about the water getting cold. V6 stated this happens on and off several times a week and it just depends on the day. On 3/20/24 at 9:19 AM, V10 Maintenance Director stated he has had multiple work orders regarding the showers in the last few…

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 Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to promote dignity while dining for four (R11, R22, R7, R23) of 24 residents reviewed for dignity in the sample list of 50. B. Based on interview and record review, the facility failed to provide timely assistance to residents when answering call lights. This failure affects five residents (R2, R45, R56, R68, and R76) of 50 reviewed for resident rights on the sample list of 50. Findings include: a.1.) On 3/19/24 at 11:30 AM, R11 was sitting at the dining room table eating lunch with R22, R7, and R23. Between bites of food, R11 coughed forcefully and R11's face turned red. R11 coughed so forcefully that R11's dentures were coming out of R11's mouth. The bites of food in R11's mouth were coughed out and landed across the table near R7's food. V16, V19, and V20 Certified Nursing Assistants were sitting across the room feeding other residents and no staff came to R11's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance for fingernail care, toenail care, shaving, and timely assistance for toileting/incontinence cares for four (R69, R81, R76, R21) of five residents reviewed for Activities of Daily Living (ADLs) in the sample list of 50 residents. Findings include: 1.) On 3/18/24 at 10:38 AM R69 stated R69 has no control of R69's urine, R69's skin is very tender, and R69 has to ask staff for toileting. R69 stated R69 hasn't seen a podiatrist since R69 admitted to the facility, and R69's toenails are long, curved past R69's toes, and are painful. R69 stated the facility told R69 that a podiatrist would be at the facility last Thursday (3/14/24) to see R69, but R69 was never seen by a podiatrist. V32 (R69's Friend) removed R69's socks. R69's toenails were thick and built up. V32 stated on 3/15/24 after supper, V31 (R69's Family) found R69 sitting in the dining room soaked with urine that was dripping from R69's wheelchair. On 3/18/24 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.

Based on observation, interview, and record review the facility failed to administer medications timely as ordered and in accordance with manufacturer's instructions for three (R7, R31, R39) of 11 residents reviewed for medication administration in the sample list of 50. This failure resulted in six medication errors out of 25 opportunities, a 24% medication error rate. Findings include: 1.) R7's March 2024 Medication Administration Record (MAR) documents D-Mannose (Urinary Tract Infection preventative) 500 milligrams (mg) by mouth, Methanamine Hippurate (anti-infective) 500 mg by mouth, and Metoprolol (decreases blood pressure) 25 mg by mouth are scheduled twice daily at 9:00 AM and 6:00 PM. On 03/18/24 at 4:22 PM V18 Licensed Practical Nurse (LPN) administered R7's medications that included D-Mannose 500 mg, Methanamine Hippurate 500 mg and Metoprolol Tartrate 25 mg, which was over an hour and thirty minutes prior to the scheduled/ordered time. 2.) R39's March 2024 MAR documents Depakote (seizure medication) Delayed Release Sprinkle 125 mg give 4 capsules (500 mg) by mouth at 8:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess for self-administration of medication for one (R6) of one resident reviewed for self-administration of medications in the sample list of 50. Findings include: On 3/18/24 at 10:40 AM R6 stated the nurses give R6's medications, but R6 does everything else on R6's own. There was a bottle of [NAME] nasal spray and a Ventolin inhaler on R6's bedside table. R6's current Physician Orders do not document an order for [NAME]. R6's Physician Order dated 3/12/21 documents Ventolin 90 micrograms per actuation inhale two puffs every four hours as needed for shortness of breath. There are no orders for R6 to self-administer these medications and no assessments for R6's ability to self-administer these medications. On 3/19/24 between 2:54 PM and 3:24 PM V2 Director of Nursing (DON) stated there should be an order and an assessment to keep medication at the bedside and to self-administer, and this would also be care planned. V2 confirmed R6 does…

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 prevent the risk of urinary tract infections by failing to prevent the back flow of urine while providing catheter care for one (R40) of three residents reviewed for catheter care on the sample list of 50. Findings include: R40's care plan dated 10/24/2018 documents R40's is at risk for Urinary Tract Infection due to catheter use. On 3/19/24 at 2:01 PM, V21 and V6 Certified Nursing Assistants provided catheter care to R40. R40 was lying in bed. After finishing with R40's catheter care, V21 and V6 stated they were going to move R40 up in bed. Urine was present in the indwelling catheter tubing that was lying on the bed. V6 took the catheter drainage bag off of the rail of the bed and placed the drainage bag on top of R40's legs. The drainage bag was placed on R40's legs below the knees. V6 then elevated the bottom half of the bed. After raising the bed, R40's legs were at a ninety angle and the drainage bag was above the level of R40's bladder. The urine inside of the catheter tubing back flowed towards 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 obtain physician orders for the administration of oxygen, change and label oxygen tubing and humidifier bottles for (R28). (R28) is one of one resident reviewed for oxygen in the sample list of 50. Findings include: R28's Physician's Order Sheet (POS) dated March 2024 has no documented orders to administer oxygen per nasal cannula, or to change oxygen tubing and humidifier bottle. R28's Facilities Census documents R28 was admitted to the facility on [DATE] and has the following medical diagnoses; heart failure, need for assistance with personal care, morbid (severe) obesity due to excess calories, venous insufficiency (chronic) (peripheral), shortness of breath, edema, and cardiac murmur. The Facilities Oxygen Administration Policy dated February 2021 documents: Purpose: The purpose of this procedure is to provide guidelines for the oxygen administration. To Administer oxygen to the resident when sufficient oxygen is being carried 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.

Based on observation, interview, and record review the facility failed to give pain medication prior to a pressure ulcer treatment for one (R40) of two residents reviewed for pain on the sample list of 50. Findings include: On 3/20/24 at 10:51 AM, R40 was lying in bed. V30 Wound Nurse/Licensed Practical Nurse turned R40 to his left side to apply a new treatment to his pressure ulcer. R40 was saying Ow when V30 was turning him. At that time, R40 stated they have not given him pain medicine today. V30 stated they can give R40 pain medication before treatments and therapy. R40's care plan with an initiation date of 10/24/18 documents R40 is at risk of pain. This care plan documents an intervention to provide pain medication prior to treatments and therapy. R40's Medication Administration Record dated March of 2024 documents an order for as needed Acetaminophen 500 milligrams two tabs as needed every eight hours and Tramadol Hydrochloride 50 milligrams every twelve as needed for pain. This record does not document that R40 received pain medication prior to his treatment.

Based on observation, interview, and record review the facility failed to attempt alternatives prior to the use of bed rails for one (R27) of one residents reviewed for bed rails on the sample list of 50. Findings include: On 3/19/24 at 11:00 AM, R27 was lying in bed. One quarter bed rails were elevated on each side of the bed. R27 stated he uses them to move in bed. R27's bed rails assessments dated 5/5/22, 11/5/23, and 1/18/24 do not document alternatives tried prior to his use of the side rails. On 3/19/24 at 12:42 PM, V2 Director of Nursing stated R27 was admitted in April of 2022, and it appears that his first bed rail assessment was completed on 5/5/22. V2 stated this bed rail assessment does not document what alternatives were attempted prior to the use of the bed rails. V2 stated R27's subsequent assessments completed on 11/5/23 and 1/18/24 do not document what was attempted either. V2 stated V2 cannot find in R27's medical record alternatives that were attempted prior to the use of the bed rails. The facility's side rail policy dated 11/20/21 documents the facility must…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess the need for emotional support after the loss of roommates (R42, R202, R203) for one (R8) of 24 residents reviewed for environment on the sample list of 50. Findings include: On [DATE] at 10:16 AM, R8 pointed over to the other side of her room and stated she (R42) is dying. The privacy curtain was pulled, and hospice staff were walking in and out of the room. R42 was lying on the bed wearing oxygen. R42's breathing was slightly labored. R8 stated all the roommates that she gets are dying. R8 stated it bothers her. R8 states they call it the dying room. R8 stated it makes her sad when her roommates die and when they put people in there to die. On [DATE] at 10:00 AM, V9 Social Service Director stated that there is no documentation that anyone has seen R8 after her room mates have passed away. V9 provided census reports that document R8's previous roommates. V9 stated that R42 passed away yesterday. V9 stated R42 went on hospice 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 ensure medication labels were legible, label eye drops with opened dates, and ensure medications were not used after expiration. This failure affects three (R39, R48, R148) of 13 residents reviewed for medication storage in the sample list of 50 residents. Findings include: 1.) R39's [DATE] Medication Administration Record (MAR) documents Lorazepam (anxiety medication) 2 MG/ML (milligrams per milliliter) give 0.25 ml by mouth twice daily at 8:00 AM and 8:00 PM and give every four hours as needed. On [DATE] at 10:02 AM V17 Licensed Practical Nurse (LPN) administered R39's medications including Lorazepam 0.25 ml. R39's Lorazepam bottle label was not legible, and the printed words were no longer visible to identify the medication and strength. R39's name and Lorazepam was handwritten on the label. V17 stated staff called pharmacy yesterday to request a new bottle of Lorazepam and V17 was unsure how long the label had been like that. V17…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide food in the consistency and texture that is prescribed for one (R11) of four residents reviewed for nutrition in the sample list of 50. Findings include: R11's Minimum Data Set, dated [DATE] documents R11 has severe cognitive impairment., has coughing or choking when swallowing medications or meals, and is on a mechanically altered diet. R11's Diet Order dated 4/9/21 documents regular diet, pureed texture, and honey consistency. R11's Speech Language Pathology Evaluation and Plan of Treatment dated 2/1/24 documents R11 has dementia and Dysphagia (trouble swallowing). This evaluation documents R11 was referred to speech therapy for coughing at meals, and a recommendation to continue pureed solids and honey thick liquids. On 3/19/24 at 11:30 AM, R11 was sitting at the dining room table eating lunch. Between bites of food, R11 coughed forcefully and R11's face turned red. R11 coughed so forcefully that R11's dentures were coming out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer and administer pneumococcal vaccines to ensure residents are up to date for two (R80, R40) of five residents reviewed for immunizations in the sample list of 50. Findings include: 1.) R80's Immunization Tab of R80's electronic medical record documents R80 received PPSV23 on 5/5/2009 and R80 is over age [AGE]. R80's March 2024 Medication Administration documents R80 admitted to the facility on [DATE]. There is no documentation that R80 was offered the pneumonia vaccine after admission or that R80 received any other doses of the pneumococcal vaccine besides the PPSV23 in 2009. 2.) R40's Immunization Tab of R40's electronic medical record documents R40 received PPSV23 on 10/31/2011, 7/28/2021, and 9/25/2021; and R40 is over age [AGE]. R40's pneumococcal vaccination consent form dated 10/14/18 documents consent for vaccine administration. There is no documentation that R40 was administered any other pneumococcal vaccines besides PPSV23. On 3/20/24 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 regularly inspect bed rails and ensure the bed rails were secured to the bed for one (R27) of one residents reviewed for bed rails on the sample list of 50. Findings include: R27's medical record documents R27 was admitted to the facility on [DATE]. This record contained a side rail assessment dated [DATE] that documents R27 uses side rails for bed mobility and positioning. On 3/19/24 at 11:00 AM, R27 was lying in bed. One quarter bed rails were elevated on each side of the bed. R27 stated he uses the bed rail to move in bed. The bed rail on R27's left side moved easily outward at least six inches when pushed toward R27 and away from R27. This bed rail did not remain securely in place to the bed's frame. On 3/19/24 at 1:18 PM, V10 Maintenance Director stated he has been here since January of 2022 and has not inspected R27's bed since he has been here. V10 stated V10 found an inspection sheet at the back of his binder where he keeps 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 repeatedly ensure residents were free of misappropriation of property/medication for two of eight residents (R1, R11) reviewed for misappropriation of property on the sample list of 11. Findings Include: The facility's Final Abuse Investigation Report for Diversion dated 1/8/24 documents on 12/29/23, a Hospice Nurse reported a concern to V1 Administrator that during a medication audit for R1, it was noted that R1's PRN (as needed) Norco {Narcotic} was only being given by one nurse at approximately the same time each day. R1 was admitted to the facility on [DATE] and on hospice on 7/18/23. V3 RN (Registered Nurse) was hired on 9/13/23 and is the primary evening shift nurse for Cart 1, where R1 resides. V2 DON (Director of Nursing) and V1 pulled narcotic sheets for R1, and it was noted that R1's PRN Norco 5-325 mg (milligram) was signed out during V3's shift at approximately the same time every shift. The narcotic sheet was compared to the MAR…

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 complete a thorough investigation into an allegation of misappropriation of property for five of eight residents (R1, R3, R8, R9, R10 and R11) reviewed for misappropriation of property on the sample list of 11. Findings Include: The facility's Reporting/Investigating Resident Abuse Policy dated April 2019 documents any individual who has reason to believe that physical abuse, mistreatment, or neglect has occurred must immediately notify the Administrator. An investigation will be initiated immediately by the Administrator/Designee. The investigation shall consist of, where possible and appropriate: an interview with the person(s) reporting the incident, the resident, any witness to the incident, staff members having contact with the resident during the period of the alleged incident, and the resident's roommate, family members, and visitors. The facility's Final Abuse Investigation Report for Diversion dated 1/8/24 documents on 12/29/23, a Hospice…

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 report an allegation of misappropriation of resident property to the resident representative for two of eight residents (R1, R11) reviewed for misappropriation of property on the sample list of 11. Findings Include: The facility's untitled Abuse Prevention Policy dated 10/3/21 documents residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent. If mistreatment has occurred, the resident's representative and Department of Public Health shall be informed as soon as possible of any allegations of abuse. The resident representative will be informed of the report of potential mistreatment, that an investigation is being conducted and the outcome of 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 timely remove a discontinued controlled medication from the medication cart for prompt destruction of the medication for one of eight residents (R11) reviewed for misappropriation of medication on the sample list of 11. Findings Include: R11's December 2023 Physician Orders document R11 had an order for Clonazepam {Benzodiazepine} 0.5 mg (milligrams) - one tablet BID (twice a day) PRN (as needed) for anxiety that was discontinued on 12/22/23. R11's undated Controlled Drug Receipt/Record/Disposition Form documents the pharmacy dispensed 30 tablets of 0.5 mg Clonazepam to the facility on [DATE]. This Form documents on 12/26/23 {4 days after medication was discontinued}and 12/27/23 {5 days after medication was discontinued}, V3 RN (Registered Nurse) signed out and removed the medication from the medication card for administration to R11, leaving 19 tablets in the medication card. This form also documents that on 1/8/24 {17 days after medication was…

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

Based on observation, interview and record review the facility failed to implement fall prevention interventions for one of three residents (R2) reviewed for falls in the sample of three. Findings Include: The facility's Fall Prevention Program dated October 2023 documents the policy is in place to provide guidelines on preventing resident falls or injury. The same policy documents staff should assess residents for fall risk and initiate risk reducing interventions. R2's undated Medical Diagnoses List documents R2 is diagnosed with Hemiplegia and Hemiparesis following a Cerebral Infarction affecting the Right Side, Lack of Coordination, Reduced Mobility, and Muscle Weakness. R2's December 2023 Physician Order Sheet documents R2 is prescribed Eliquis (Anticoagulant) 5 milligrams twice daily for Atrial Fibrillation. R2's Fall Scale dated 10/3/23 documents R2 was a moderate fall risk due to medical diagnoses, impaired and weakened gait, non-ambulatory, and self-propels in her wheelchair. R2's Fall Report dated 12/3/23 documents on 12/3/23 at 11:00 PM R2 was found on the floor by her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to evaluate pain and manage pain for one (R1) of four residents reviewed for falls in the sample list of four. Findings include: The facility's Management of Pain policy revised August 2019 documents: Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. On 10/23/23 at 1:09 PM R1 stated R1 has left hip pain frequently, every time R1 moves. R1 rated R1's pain as a 7 or 8 on a 1-10 scale. R1 stated it hurts bad enough that R1 tells the staff about R1's pain. R1 stated R1 does not get offered any pain medication. On 10/23/23 at 1:39 PM V9 and V10 Certified Nursing Assistants transferred R1 from the wheelchair to the bed. R1 stood and during the transfer said ow. R1 said ouch when the staff lifted R1's legs into the bed. R1 had scarring to the left thigh incision, where staples had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide timely response to requests for toileting and incontinence care, and failed to provide timely incontinence care for six residents (R1, R2, R4, R5, R6, R7) reviewed for toileting assistance/incontinence care in the sample list of seven. Findings include: 1.) On 7/31/23 at 8:42 AM R1 stated R1 waits over an hour at times for R1's call light to be answered and R1 has to wait for incontinence care. R1 stated R1 requires two staff to provide R1's incontinence care, so R1 has to wait while the staff goes to find assistance. On 7/31/23 at 1:32 PM V7 Certified Nursing Assistant (CNA) answered R1's call light. R1 requested incontinence care. V7 told R1 that V7 needed assistance and V7 would return. V7 left R1's room. At 1:47 PM R1 stated R1 was incontinent of urine and V7 told R1 that V7 needed to find additional assistance, and V7 has not yet returned. At 1:48 PM V7 and V5 transferred R6 (another resident on R1's unit) into bed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide showers as scheduled for three (R1, R2, R3) of four residents reviewed for showers in the sample list of seven. Findings include: 1.) On 7/31/23 at 8:42 AM R1 stated there have been issues with R1 getting showers, and R1 is scheduled to receive showers twice per week. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and is dependent on one staff person for bathing assistance. R1's Care Plan revised 11/17/21 documents R1 has an Activity of Daily Living self care deficit and includes an intervention (R1) is totally dependent on (2) staff to provide bath/shower twice weekly and as necessary. R1's shower documentation documents R1's showers are scheduled twice weekly on Tuesdays and Fridays, not applicable is documented on 6/9/23, 6/13/23, 7/21/23 and 7/25/23. There is no documentation that R1 was offered or provided a shower from 6/9/23 until 6/15/23 and from 7/20/23 until 7/28/23. 2.) On 7/31/23 at 8:48 AM R2 stated…

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.