Loft Rehab Of Peoria, The

Based on interview and record review, the facility failed to provide written notification of transfer to the hospital to a resident's representative (R8) and failed to notify the facility Ombudsman of resident Discharges/Transfers monthly for three residents (R8, R65, R84) of four reviewed for discharges in the sample of 33. Findings include: 1. R65's Social Service Note, dated 8/6/24 at 3:07 pm, documents R65 was accepted to a new facility. R65 will be picked up on 8/10/24 at 8:00 am. Please have R65 ready. R65's Face Sheet, printed 8/22/24, documents R65 was discharged on 8/10/24 to another facility. The Admission/Discharge Log, dated 7/10/24 to 8/10/24, does not document R65 was discharged to another facility. 2. R84's Nursing Note written by V12/Licensed Practical Nurse, dated 8/3/24 at 11:36 pm, documents R84 called V12 to his room, and R84 complained of shortness of breath and chest pains. R84's oxygen level was at 88 percent. R84 stated he wanted to go back to the hospital. R84 had just come back from the hospital at 10:30 am. R84 stated he would feel better if he went 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 interview and record review, the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital for one of three residents (R8) reviewed for bed holds in the sample of 33. Findings Include: R8's clinical record documents R8 was hospitalized on [DATE]. R8's clinical record does not contain documentation of written notice of the facility bed hold policy. On 8/22/24, at 3:15pm, V1, Administrator, was unable to produce any documentation the facility's bed hold policy was provided to R8 or R8's representative.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident on a mechanically altered diet was provided supervision at meals as ordered for one (R2) of 18 residents reviewed for meal supervision in a sample of 33. Findings include: The facility's Certified Nursing Assistant Job Description, dated June 2021, documents, Food Service Functions: Serve food trays. Assist with feeding as indicated (i.e. cutting foods, feeding, assist in dining room supervision, etc.). The facility's Comprehensive Care Plans policy, revised 1/25/23, documents, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter bag and tubing were not touching the floor and the urinary bag was covered for one (R2) resident of two residents reviewed for urinary catheters in a sample of 33. Findings include: The facility's Catheter Care policy, revised 1/24/23, documents, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. R2's current Physician Order Sheet/POS documents R2 has a urinary catheter. On 8/20/24, at 10:24 am, R2 is in bed with an uncovered indwelling urinary catheter bag draining yellow urine. R2's catheter bag and tubing are touching the floor. On 8/20/24, at 12:44 pm, R2 was in bed with an indwelling urinary catheter bag and tubing touching the floor. On 8/20/24, at12:50 pm, V8, Certified 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 observation, interview, and record review, the facility failed to place an oxygen sign outside resident bedrooms for two residents (R8 and R14), have a physician order for the cares and administration of oxygen for one resident (R8), and failed to change oxygen tubing/humidifier bottles per facility policy for one resident (R18) of three residents reviewed for oxygen therapy in the sample of 33. Findings Include: The Oxygen Policy, dated 5/10/21, documents, Oxygen is administered to residents who need it. Consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. 8. Storage of oxygen shall be in accordance with the facility's Oxygen Safety Policy. 1. R14's Physician Order, dated 3/12/24, documents oxygen at 2 (two) liters per minute by nasal cannula every shift. R14's Care Plan documents R14 has altered respiratory status/difficulty breathing related to Sleep Apnea, Chronic Obstructive Pulmonary…

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 provide documentation of collaboration of care between the facility and the Dialysis center for one of one resident (R66) reviewed for Dialysis in a sample of 33. Findings include: The facility's Dialysis policy, revised 2/14/24, documents, Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders the comprehensive person-centered care plan, and the residents' goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving dialysis. Policy Explanation and Compliance Guidelines: 4. Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed. 5. If no written report is received upon return from dialysis, nursing staff will call the dialysis provider to receive a report. R66's Treatment Administration Record/TAR, dated August 2024, documents R66 receives Dialysis. On 8/20/24, at 10:59 am, R66…

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 proper PPE (Personal Protective Equipment) was donned and handwashing was performed for one COVID-19 (Coronavirus Disease of 2019) positive resident (R58), and failed to ensure Enhanced Barrier Precautions signage was posted for one resident with an indwelling urinary catheter (R2) of 18 reviewed for infection control in a sample of 33. Findings include: 1. The facility's COVID-19 Prevention, Response and Reporting policy, revised 5/31/24, documents, Policy Explanation and Compliance Guidelines: 16. HCP (Health Care Personnel) who enter the room of a resident with suspected or confirmed SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) infection should adhere to standard precautions and use a NIOSH (National Institute for Occupational Safety and Health) - approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. On 8/20/24, at 12:41 pm, R58 was in a COVID-19 isolation room. V8, Certified Nursing Assistant/CNA, entered R58's room carrying a meal tray with a…

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

Based on interview and record review, the facility failed to prevent staff to resident verbal/mental abuse for one resident (R11) of four residents reviewed for abuse in the sample of 17. Findings include: Facility Policy/Abuse Neglect and Exploitation, dated 12/5/22, documents: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Willful means the individual deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse means the use of oral,…

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

Based on interview and record review, the facility failed to report an allegation of verbal abuse to the State Agency for one resident (R5) of four residents reviewed for abuse in a sample of 17. Findings include: Facility Policy/Abuse, Neglect and Exploitation, dated 12/5/22, documents: The Abuse coordinator in the facility is the Administrator, or facility designee. Report allegations or suspected abuse, neglect or exploitation immediately to: Administrator or designee Other Officials in accordance with State Law State Survey and Certification agency through established procedures. Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend or disability. When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Anyone in 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 interview and record review, the facility failed to develop an oxygen care plan for one (R3) of three residents reviewed for oxygen in a sample of five. Findings include: Facility Care plan policy, dated 12/06/22, documents, Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: Physician orders. On 3/6/24 at 9:30 AM, R3 was in the front lobby alert and oriented with portable oxygen on via nasal cannula. R3's current care plan has no documentation R3 wear oxygen. On 3/12/24 at 1:48 PM, V1, Administrator, verified R3's current care plan did not have R3's oxygen listed on it, and he wears oxygen every day.

Based on interview and record review, the facility failed to process orders for an Iron medication for one (R1) of three residents reviewed for medications in a sample of six. Findings include: Facility Physician/Practitioner Orders, dated 12/13/22, documents, For physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: If not the Attending, call the attending physician to verify the order. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. For physician/practitioner orders received via telephone, the nurse will: Document the order on the physician order form, noting the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. If not the Attending, call the attending physician to verify the order. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment…

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

Based on interview and record review, the facility failed to obtain orders/cares for a colostomy for one (R2) of one residents reviewed for colostomies in a sample of five. Findings include: Online Wound, Ostomy, and Continence Society Article, undated, documents, General maintenance care of a Colostomy is needed daily. R2's admit diagnosis, dated 2/14/24, documents, COLOSTOMY STATUS. R2's February 2024 physician orders has no documentation for R2's Colostomy cares. R2's nurses notes, dated 2/14/2024 at 9:24pm by V10, LPN/Licensed Practical Nurse, documents, Resident (R2) arrived to the facility via transport. Family arrived shortly before resident, delivering numerous medical supplies for Colostomy care. On 3/6/24 at 12:23pm, V3, R2's Power of Attorney/POA, stated, (R2) was admitted to (nursing home) in February 2024 with her colostomy. (R2) was in the hospital and got her colostomy on January 7 2024. On 3/12/24 at 1:48pm, V1, Administrator, verified R2 did not have any orders for R2's Colostomy. During this survey, V1 was asked on two separate occasions to provide a Colostomy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have sufficient oxygen for a doctor appointment, and failed to have oxygen orders for two (R1 and R3) of three residents reviewed for oxygen in a sample of five. Findings include: Facility Oxygen Administration, dated 5/10/21, documents, Oxygen is administered to residents who need it. Oxygen is administered under orders of a physician. 1. R1's current physician orders documents an order from 10/16/23 for Oxygen 2 liters nasal cannula. On 3/6 /24 at 10:00 AM, R1 stated, I went to the (doctor appointment) and used their oxygen because I ran out, and was transferred back to the nursing home with no oxygen. My tank was empty. At that same time, R1 was wearing portable oxygen by nasal cannula and was alert and oriented. On 3/6/24 at 12:40pm, V4, NP/Nurse Practitioner for a cancer center, stated, (R1) is on oxygen, came to his appointment with a partial tank, we were not running behind. (R1) ran out of oxygen and used ours, his transport…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two Emergency Carts reviewed were stocked with necessary emergency equipment, and failed to ensure both carts were checked every 24 hours per facility policy. This failure has the potential to affect all 102 residents in the facility. Findings include: On [DATE] Resident Room Roster indicated resident census was 102. Facility Policy/Emergency Crash Cart, dated [DATE], documents: The purpose of this policy is to ensure that all supplies critical to basic life support are readily available on the Emergency Cart. Equipment/supplies used from the Emergency Cart are noted and replaced promptly. The Emergency Crash Cart is checked every 24 hours and after every use. Missing or expired items are replaced, when applicable. Clinical staff will be educated on the location and use of the Emergency Crash Cart. Equipment/supplies from the Emergency Cart are used only when emergency care is provided. Facility Emergency Cart Check List…

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 sufficient nurse staffing. This failure has the potential to affect all 102 residents in the facility. Findings include: Facility Assessment, dated 12/2023, documents: Indicate the number of residents you are licensed to provide care for: 120 Indicate your average daily census: (enter a range) 70 -89 Number (enter average or range) of persons admitted Number (enter average or range) of persons discharged Weekday 1-4 1-4 Weekend 1-4 1-4 Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Direct Care Staffing approach is done by utilizing the following calculation for Minimum staffing levels: (Total Skilled census X 3.8 HPPD/Hours of Care Per Patient Day) + (Total intermediate Census X 2.5 HPPD) Total Direct Care Distribution is done by utilizing the following distribution matrix: A minimum…

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

Based on interview and record review, the facility failed to administer a narcotic pain medication per order for one (R1) of three residents reviewed for pain in a sample of three. Findings include: Facility Medication Administration, revised 1/4/23, documents, Medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. R1's current careplan documents, (R1) has actual pain related to fibromyalgia, generalized pain, back pain, and right wrist pain. Administer and monitor for effectiveness from routine and PRN (as needed) pain medications. R1's current Physician Order Sheet/POS, with a start date of 9/2/23, documents, Morphine Sulfate ER Tablet Extended Release 15mg/milligrams give one tablet by mouth every 12 hours for pain. R1's Medication Administration Record/MAR, dated September 1- September 30th, 2023, documents R1's Morphine Sulfate ER 15mg pain medication was not given on 9/20/23 at 8pm, and 9/21/23 at 8am. On 1/25/24 at 11:15am, V7, LPN/Licensed Practical Nurse, stated, We document medications given by…

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 up on a physician authorization request and ensure a physician ordered narcotic medication was available for administration for one (R1) of three residents reviewed for medications in a sample of three. Findings include: Facility Medication Administration, revised 1/4/23, documents, Medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. R1's current Physician Order Sheet/POS, with a start date of 9/2/23, documents, Morphine Sulfate ER Tablet Extended Release 15mg/milligrams give one tablet by mouth every 12 hours for pain. R1's Medication Administration Record/MAR, dated September 1- September 30th, 2023, documents R1's Morphine Sulfate ER 15mg pain medication was not given on 9/20/23 at 8pm, and 9/21/23 at 8am. On 9/20/2023 at 9:40pm, V17, RN/Registered Nurse, documented, (R1) is very upset due to not having her scheduled morphine in stock. Pharmacy reported that the insurance company is waiting for pre authorization in…

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

Based on observation, interview, and record review, the facility failed to prevent a urine like smell emanating down two resident hallways, and failed to clean the dining room between meals. This failure has the potential to affect all 98 residents residing in the facility. Findings include: The facility's Environmental Services Cleaning Procedures for Common Items, dated 2022, documents, Floors: Clean on a regular basis. When soiled. Between residents & after discharge. Damp mopping. 1. On 12/13/23 at 11:00 AM, upon entry of the 300 and 400 resident hallway nurses station, a faint urine like odor could be detected. Upon walking down 300 hallway, the urine like odor became stronger leading up to R5's room, where the urine like odor was very prominent. On 12/13/23 at 11:12 AM, upon walking down 400 hallway, the urine like odor became stronger leading up to R4's room, where the urine like odor was very prominent. On 12/13/23 at 11:16 AM, V10, Certified Nursing Assistant (CNA), stated, That urine smell is coming from (R4)'s room. She's able to get herself to the bathroom, but waits too…

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 trim nails, shave facial hair, and comb the hair of three residents (R3, R9 and R17), and failed to provide showers to two residents (R2 and R10) out of eight residents reviewed for activities of daily living is a sample of 17. Findings include: The facility's Activities of Daily Living policy, dated 10/5/23, documents, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 1. On 12/13/23 at 1:50 PM, R3 observed lying in bed with fingernails grown past the tips of his fingers, long facial hair, and disheveled hair. R3 stated, I haven't been shaved in probably three weeks. I couldn't tell you the last time my nails got trimmed. Look at my hair! I need a haircut. I would like them to at least comb it everyday. On 12/13 23 at 1:58 PM, R9 observed lying in bed with facial hair, uncombed hair, and fingernails that are past the tips of his fingers. R9 stated, I got here on Sunday and I haven't been shaved or had my nails trimmed since 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.

Based on observation, interview, and record review, the facility failed to complete dressing changes as ordered by a physician for one resident (R3) out of three residents reviewed for wound care in a sample of 17. Findings include: The facility's Wound Treatment Management, dated 8/1/19, documents, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. R3's medical record documents, Transmetatarsal Amputation of the left foot, Achilles tendon lengthening of the left foot. R3's medical record documents (0.25% sodium hypochlorite (NaClO) solution). Apply to let foot topically every shift related to acquired absence of left foot. Apply 0.25% sodium hypochlorite (NaClO) solution) to (gauze) cover with ABD (abdominal) pad wrap with (rolled gauze). R3's treatment administration record (TAR), dated December 2023, does not document R3's left foot treatment was completed 12/5 and 12/6. It also does not document the treatments were completed on night shift on 12/1, 12/3, 12/4, 12/6, 12/9 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 maintain transmission based precautions for one resident (R10) out of three residents reviewed for transmission based precautions in a sample of 17. Findings include: The facility's Transmission Based Precautions policy, dated 12/2/21, documents, 3. Contact Precautions- a. Intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on case-by-case basis, balancing infection risks to other residents, the presence of risk factors that increase the likelihood of transmission, and the potential adverse psychological impact on the infected or colonized resident. c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon…

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 a resident's fingernails were clean and trimmed for one (R1) of three residents reviewed for grooming in a sample of nine. Findings include: The facility's Standards and Guidelines: Nail Care policy, revised 3/27/21, documents, Standard: It will be the standard of this facility to provide nail care to residents per resident preferences and to maintain dignity. Guidelines: 3. Nail care includes regular cleaning and regular trimming, unless contraindicated by resident condition, specific behaviors or resident refusal. 4. Proper nail care can aid in the prevention of skin problems around the nail bed .6. Trimmed and smooth nails can help prevent the resident from accidentally scratching an injuring his or her skin. R1's Minimum Data Set/MDS assessment, dated 8/23/23, documents R1 is cognitively intact and requires extensive assist with one assist for personal hygiene. On 11/15/23, at 9:55am, R1 was in bed with R1's left hand clenched closed. When R1 opened his left hand there were two deep marks in his…

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 upon observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment. This failure has the potential to affect all 102 residents currently residing in the facility. Findings include: The facility's Standards and Guidelines: Housekeeping, revised 11/1/2016 states, Standard: It will be the standard of this facility to provide effective and sanitary housekeeping and maintenance services. The Residents' Rights for People in Long Term Care Facilities documents residents have the right to a safe, clean, comfortable, and homelike environment. The facility's Floor Tech Job Description, undated documents floor care of the facility including resident rooms will be provided and maintained to include stripping; waxing; and buffing. This same policy states, Maintaining the environment of the facility to create a positive physical and psychosocial environment for the residents. Ensure residents' rooms are safe, comfortable, and maintained in an attractive manner. Clean up spills, soiled areas, and other conditions as observed 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 transfer a resident with a mechanical lift according to a resident's plan of care for one of three residents (R2) reviewed for supervision in the sample of seven. Findings include: The facility's Standards and Guidelines: Mechanical Lifts, revised 3/27/21 states, Standard: It is the standard of this facility to provide a safe environment for our residents and staff. Guidelines: 4. The use of the mechanical lift should be included in the resident's plan of care. 5. When using the mechanical lift staff will adhere to manufacturer's guidelines, physician's orders and/or the plan of care. The Full Mechanical Lift Guidelines dated January 2014 documents there are circumstances such as combativeness, obesity, contracture, etc. of the individual that may dictate the need for a two-person transfer. These guidelines state, It is the responsibility of each facility or medical professional to determine if a one- or two-person transfer is more appropriate, based on the task, resident load, environment, capability, 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 call lights were answered in a timely manner for four of 14 residents (R5, R13, R14 and R15) reviewed for resident rights in the sample of 17. Findings include: The facility's Standards and Guidelines: Call Lights, revised 9/15/2022, documents residents' call lights should be answered as soon as possible. The facility's Standards and Guidelines: Resident Rights Dignity, and Visitation Rights, revised 9/8/2022, states, Standard: It will be the standard of this facility that employees shall treat residents with kindness, respect and dignity. The facility will promote care for residents in a manner and in an environment that maintains or enhances dignity and respect in recognition of his or her individuality, preferences, activities, pursuits, goals and desires. The facility's Resident Council Meeting Minutes for August 2023 documents, Takes way too long to get bathroom care. The facility's Resident Council Meeting Minutes for September 2023 documents, CNAs (Certified Nursing Assistants) not to be found…

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 handwashing and don PPE/Personal Protective Equipment prior to entering a COVID-19 positive room, and failed to perform hand hygiene upon exiting a COVID-19 positive resident room for ten of 14 residents (R2-R11) reviewed for infection control in the sample of 17. Findings include: The facility's Standards and Guidelines: Transmission-Based Precautions, revised 9/1/22 states, Several routes transmit microorganisms in healthcare facilities. Moreover, more than one route may transmit the same microorganism. There are several categories of Transmission-Based Precautions and the main routes of transmission in typical Healthcare Associated Infections (HAI). COVID-19 Specific - Per the direction of CDC (Centers for Disease Control and Prevention), Special Contact/Droplet precautions are to be carried out for residents identified as having SARS-CoV-2 virus (COVID-19), COVID-19 PUI (Persons Under Investigation), or new admission preventative precautions. Contact: Direct contact with skin, or indirect contact…

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 a resident's privacy and dignity during incontinence care for one of 14 residents (R13) reviewed for resident rights in the sample of 17. Findings include: The facility's Standards and Guidelines: Resident Rights Dignity, and Visitation Rights, revised 9/8/2022, states, Standard: It will be the standard of this facility that employees shall treat residents with kindness, respect, and dignity. 3. The facility will make effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity; providing care that is comfortable and consistent with his/her normal life habits, observing resident's choices whenever able. 4. The facility will promote care for residents in a manner and in an environment that maintains or enhances dignity and respect in recognition of his or her individuality, preferences, activities, pursuits, goals and desires. R13's Minimum Data Set/MDS Assessment, dated 10/19/23, documents R13 as cognitively intact. On…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's call light was within reach for one of 14 residents (R13) reviewed for accommodation of needs in the sample of 17. Findings include: The facility's Call Lights Standard and Guidelines, revised 9/15/2022, states, It will be the standard of this facility to respond to the resident's requests and needs via notification with the call light system. When the resident is in bed, confined to a chair or using the toilet and bathing facilities, the call light should be within easy reach of the resident. R13's current admission Record documents R13 with diagnoses to include but not limited to: Severe right eye blindness and low vision of the left eye; Cerebral Infarction with left sided hemiparesis and hemiplegia; Muscle Weakness; and Lack of Coordination. R13's Minimum Data Set/MDS Assessment, dated 10/19/23, documents the following: R13 is cognitively intact; R13 requires substantial/maximal assistance for eating and toileting; R13 is dependent on staff for showering/bathing and dressing; and R13…

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 showers (R13 and R14) and shaving assistance (R13) to residents who required assistance with Activities of Daily Living/ADLs for two of three residents (R13 and R14) reviewed for activities of daily living in the sample of 17. Findings include: The facility's Standards and Guidelines: Showers/Bathing, revised 3/27/21, states, Standard: It will be the standard of this facility to assure that showers/bathing are offered to residents at least 2 (two) times weekly or per resident/resident representative preference unless specifically ordered otherwise by the physician or care planned otherwise. Guidelines: 1. A schedule will be developed for each resident with showers (or bed bath or alternate means of bathing) according to room placement or resident preferences. CNAs/Certified Nursing Assistants/nursing staff should complete the assignment sheet/shower sheet or POC (Point of Care) electronic documentation on each day shower/bathing…

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 weights per facility policy (R13 and R14) and failed to ensure a resident was provided hydration (R13) for two of three residents (R13 and R14) reviewed for dietary needs in the sample of 17. Findings include: The facility's Weighing/Weight Loss Protocol, revised 3/5/21,, states, Guidelines: New Admits and readmissions will be weighed upon admission, monthly and/or as ordered by the physician. 1. Staff will be responsible for obtaining weights for these admits and will have this information available for morning stand-up meeting. Weights will be recorded. 4. Consistent weight loss noted during the admission weight process will be brought to the attention of the MD & responsible party. 5. Weight refusals, not consistent with the resident's known preferences or expressed desires, should be documented by the attending nurse in the resident/patient's chart with notification to MD and responsible party. This same policy documents 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 interview and record review, the facility failed to follow its policy and offer an option of similar nutritive food to a resident who choose not to eat food that is initially served for one of three residents (R13) reviewed for dietary needs in the sample of 17. Findings include: The facility's Menus Planning Standards and Guidelines, revised 2/19/21, states, Standard: Nutritional needs of individuals will be provided in accordance with the recommended dietary allowances according with established national guidelines and adjusted for age, gender, activity level and disability through nourishing, well-balanced diets, unless contraindicated by medical needs. Based on a facility's reasonable efforts, menus should reflect the religious, cultural, and ethnic needs of the resident population, as well as input received from residents and resident groups. 4. Residents who choose not eat food or drink that is initially served or who request a different meal choice will be offered the opportunity to receive substitutes. 5. A replacement item is selected that is nutritionally…

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 staff were wearing name (identification) tags, were not wearing/using cell phone devices during their shift and/or cares, and were treating residents with respect. This has the potential to affect all 90 residents residing in the facility. Findings include: The facility's Resident Rights, Dignity and Visitation Rights policy, dated 8-29-20, documents, It is the standard of this facility that residents will be afforded all rights guaranteed under the Constitutions of the United State and the State of Illinois, federal, State and local statutes and the department's administrative rules. It is the standard of this facility that employees will treat residents with kindness, respect and dignity .5. The facility will promote care for residents in a manner and in an environment that maintains or enhances dignity and respect in recognition of his or her individuality, preferences, activities, pursuits, goals and desires .Be treated at all times with courtesy, respect and full recognition of personal dignity…

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 record review and interview, the facility failed to ensure residents' meals were served on non-disposable dinnerware. This failure has the potential to affect all residents who consume food in the facility, except R58, R191, and R344, who are NPO (nothing by mouth). Findings include: The facility's Residents Council Meeting Minutes, dated 1/18/23, documents, Nursing: Residents would like facility to be more homelike environment. The facility's Residents Council Meeting Minutes, dated 4/13/22 and 5/15/22 documents: Residents are frustrated and feeling nothing is being done, concerning past issues mainly in Dietary Department. On 6/1/23 at 9:30am, V13, Dietary Manager, stated her Dietary Department staff had used disposable Styrofoam dinnerware at least two times a week during April and May 2023. (V13 indicated a large half full box of three-compartmental disposable Styrofoam dinnerware.) V13 stated, We used these (Styrofoam Dinnerware) in emergency situations when we had call-offs and staff not showing up, or when there was no dishwasher to do the dishes. At this same time,…

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, record review, and interview, the facility failed to ensure food items were stored and labeled with dates and identification. This failure has the potential to affect all residents who consume food in the facility, except R58, R191, and R344 who are NPO (nothing by mouth). Findings include: The facility's Food Labeling and Dating Policy, revised 3/2/21, documents: Standard: Foods are labeled and dated for identification purposes and to ensure they are discarded within acceptable time frames 2. Opened and perishable items are discarded after 72 hours or dated with the used by date. This may include the date by which it should be sold, eaten or thrown out. The facility's Unit Pantry Food Storage Policy, revised 3/2/21, documents: Label containers with food item name and date received. On 5/30/23 at 8:40am, a plastic bag containing frozen chocolate chip cookies and a small bowl of ice cream (uncovered) in the facility's two-door freezer were not labeled or dated with identification. At this time, V13, Dietary Manager, stated these items should have been labeled…

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 residents felt safe and comfortable when reporting any concern or grievance to the facility for five of five residents (R4, R6, R13, R60, and R70) reviewed during resident council in a sample of 37. Findings include: The facility's Residents' Rights for People in Long-term Care Facilities, undated, documents, You have the right to present grievances and to get a prompt response from the facility. Your facility may not threaten or punish you in any way for asserting your rights or presenting grievances. The facility's Grievances policy, revised 3/21/21, documents, Standard: It will be the standard of this facility to provide resident, resident representatives, family an visitors with methods of sharing grievances and/or concern with the facility. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment…

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 daily personal hygiene/grooming care for four residents (R18, R22, R23 and R58), failed to provide incontinence care to prevent over saturation of an incontinence brief for one resident (R46), and failed to change visibly soiled linen for one resident (R13) out of six residents reviewed for activities of daily living in a sample of 37. Findings include: The facility's ADL (Activities of Daily Living) Care and Assistance policy revised 3/27/21 documents, It will the standard of this facility to provide the resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest practicable level of function for the resident. The facility's Shower/Bathing policy, revised 3/27/21, documents, Standard: It will be the standard of this facility to assure that showers/bathing are offered to residents at least two times weekly or per resident/resident representative preference unless specifically ordered otherwise by the physician or care planned otherwise. 1. The current…

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 fall interventions were implemented for two (R23 and R46) of five residents reviewed for falls, and failed to follow the facility smoking policy for three (R17, R37, and R76) of four residents reviewed for smoking in the sample of 37. Findings include: 1. The facility's Fall Prevention policy and procedure, revised 3/27/21, documents, Based on evaluation of an existing fall(s) pertinent interventions will be implemented by staff such as, but not limited to: resident education if appropriate, staff re-education regarding transfer techniques and safety during ADL care, resident footwear, appropriate lighting, maintaining close proximity of frequently used items, medication reviews, toileting programs, use of hip protectors, referral to therapy for strengthening/coordination/balance, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications, use of fall prevention programs that provide more frequent supervision and restraints, if…

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 residents took their medications for two (R56 and R76) of two residents reviewed for self administration of medications in the sample of 37. Findings include: The facility's Self-Administration of Medications policy and procedure, revised 3/27/21, documents, It is the standard of this facility that residents who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Guidelines: 1. As part of the overall evaluation, the staff and practitioner will assess or evaluate each resident's mental and physical abilities to determine whether a resident is capable of self-administering medications. 2. In addition to general evaluation of decision making capacity, the staff and practitioner will perform a more specific skill assessment . The facility's Medication Administration policy and procedure, revised 3/27/21, documents, After successfully identifying the resident to receive medication administration, the individual administering the medication should…

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

Based on observation, interview, and record review, the facility failed to ensure call lights were within resident reach for two (R38 and R46) of 19 residents reviewed for call light's in the sample of 37. Findings include: The facility's Call Lights policy and procedure, revised 9/15/2022, documents, It will be the standard of this facility to respond to the resident's requests and needs via notification with the call light system. When the resident is in bed, confined to a chair or using the toilet and bathing facilities, the call light should be within easy reach of the resident. 1. The quarterly MDS (Minimum Data Set) assessment for R46, dated 3/20/23, documents R46 requires assistance with activities of daily living, has bilateral lower extremity impairments, and is a high risk for falls. The current Care Plan for R46 documents R46 is at risk for falls, with an intervention to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 5/30/23 at 9:00 am, R46 was sitting up in a wheelchair in her room, crying. R46's call…

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 internally report an alleged case of verbal/emotional staff to resident abuse for one of four residents (R13) reviewed for abuse in a sample of 37. Findings include: The facility's Abuse, Neglect, Exploitation and Investigations policy, revised 9/8/22, documents, Standards: It will be the standard of this facility to honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the residents' symptoms in accordance with Federal Law. It will be the standard of this facility to ensure that all alleged violations of Federal or State laws, which involve mistreatment, neglect, abuse (verbal, mental, physical or sexual), injures of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use or physical or chemical…

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 an alleged case of verbal/emotional staff to resident abuse for one of four residents (R13) reviewed for abuse in a sample of 37. Findings include: The facility's Abuse, Neglect, Exploitation and Investigations policy, revised 9/8/22, documents Standards: It will be the standard of this facility to honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the residents' symptoms in accordance with Federal Law .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical 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 record review and interview, the facility failed to perform blood glucose monitoring for one diabetic resident (R343) of three reviewed for glucose monitoring in a total sample of 37. Findings Include: R343's Medical Record documents she was admitted on [DATE], with a diagnosis of Type 2 Non Insulin Dependent Diabetes. R343's Admitting Physician's Order, dated 4/5/23, documents, Give Glimerpride 1 mg (milligram) daily for Type 2 Diabetes. R343's Physician Order Sheet, dated 4/6/23, documents, Check blood sugar every morning. R343's Medication Administration Record for April 2023 documents blood sugar monitoring started on 4/13/23. On 6/1/23, V2 (Director of Nursing) stated, Yes, we missed her accucheck (blood glucose monitoring) for a week when she was admitted . We should have caught that and been doing them since 4/13/23.

Based on observation, interview, and record review, the facility failed to provide range of motion (ROM) exercises to prevent further contracture for one resident (R32) out of five residents reviewed for limited range of motion in a sample of 37. Findings include: The facility's Contracture Management, revised 3/1/21, documents, It will be the standard of this facility that the facility must ensure that a resident with a limited range of motion (ROM) receives appropriate treatment to increase range of motion and/or prevent further decrease in ROM. R32's current care plan documents, Every shift: Perform PROM (Passive Range of Motion) exercises to bilateral lower extremities and upper extremities into flexion/extension, abduction/adduction, knee/elbow flexion/extension, wrist/ankles flexion/extension times 10 reps. Dated initiated 2/10/20. R32's medical record does not document range of motion exercises have been completed. R32's Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 1/20/23, documents, Musculoskeletal System Assessment: AROM (Active Range of Motion) Left…

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 incontinent residents receive incontinence care in a timely manner for one (R13) of two residents reviewed for bowel and bladder incontienece, and failed to ensure indwelling urinary catheters were secured in a way to prevent cross contamination for two (R23 and R58) of two residents reviewed for urinary catheters in the sample of 37. Findings include: 1. The facility's Perineal/Incontinence Care policy, revised 10/24/22, documents, Standard It will be the standard of this facility to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe th resident's skin condition and provided appropriate care and service required to maintain functional levels while providing perineal/incontinence care .Guidelines: 6. (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. R13's admission Minimum Data Set/MDS assessment, dated 5/3/23, documents…

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 for gastronomy tube (G-tube) dressing change for one resident (R22) out of two resident reviewed for tube feedings in a sample of 37. Findings include: The facility's Enteral Tube Feeding policy, revised 3/27/21, documents, 13. Provide cleaning and dressing changes as ordered to enteral tube feeding sites (i.e. gastronomy or jejunostomy). R22's physician order sheet documents, 6/29/22: G-Tube site care - specify frequency and any special instructions. Every day. Every night shift. R22's treatment administration record (TAR), dated 5/1/23 through 5/31/23, does not document R22's G-tube bandage was completed on 5/27/23. On 05/30/23 10:08 am, R22 was lying in bed receiving morning cares. The G-tube dressing was dated 5/28/23. V5, Certified Nursing Assistant (CNA), verified date on bandage. On 5/30/22 at 10:08 am, R22 stated his G-tube bandage has not been changed in a couple of days. On 5/31/23 at 8:40 am, V7, Wound Nurse, stated, (R22)'s G-tube bandage is scheduled to be changed every…

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 the Quality Assurance and Assessment (QAA) meetings were held at least quarterly. This failure has the potential to affect all 81 residents residing in the facility. Findings include: The facility's QAA Committee Meeting Minutes sign in sheets, provided by V1 (Administrator), document there were only two quarterly QAA meetings held (12/6/21 and 3/7/22) in the past four quarters. On 4/5/22 at 1:27 PM, V1 (Administrator) stated there is no documentation the facility held quarterly QAA meetings for the second and third quarters of 2021. The Resident Census and Condition Report, dated 4/3/22, and signed by V6 (Regional Director) documents 81 residents currently reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide range of motion and mobility programs for residents with identified limitations of range of motion and mobility for eight of ten residents (R22, R23, R25, R32, R33, R40, R52, R56) reviewed for range of motion/mobility in the sample of 33. Findings include: 1.R22's Minimum Data Set (MDS) assessment, dated 1/14/22, documents R22 needs limited assistance of one staff for walking; R22 has limitation of range of motion in bilateral lower extremities; and R22 has no restorative nursing programs for walking or range of motion. R22's Care Plan, dated 1/19/22, documents R22 has a self-care performance deficit related to Activity of Daily Living (ADL) needs and Diagnosis of Dementia. R22's Care Plan documents R22 can ambulate with limited assistance of one staff member. R22's Physician Order Sheet documents R22 received Physical Therapy from 12/16/22 through 2/9/22. R22's Medical Record does not include documentation of a…

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

Based on observation, interview, and record review, the facility failed to reconcile controlled medications for 10 of 10 residents (R41, R42, R226, R227, R327, R328, R329, R330, R333 and R334) reviewed for medications, in the sample of 33. FINDINGS INCLUDE: R41's current Physician Order Sheet, dated April 2022, includes the following medications: Norco (controlled substance) 5/325 MG (Milligrams) Give 1 tablet by mouth four times a day for pain. On 4/3/22 at 7:34 AM, V3/Licensed Practical Nurse (LPN) prepared to administer medications for R41. V3/LPN unlocked the 100 Hall Controlled Substance box, located in the 100 Hall Medication Cart, withdrew a medication punch card and punched one tablet of Norco 5/325 MG into a plastic medication cup. V3/LPN then opened the blue 100 Hall Narc (Narcotic) Book and signed out the medication. At that time, the Shift To Shift Count Sheet, dated 2/16/22 through 3/14/22, documented twenty two missed shift to shift nursing narcotic counts. There were no required nursing shift to shift narcotic counts for March 15, 2022 through April 3,2022. An…

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

Based on interview, record review, and observation, the facility failed to check for gastrointestinal placement, residual, and elevate the head of the bed to a 30 to 35 degree angle for one resident (R32) of two reviewed for gastrostomy tubes in a sample of 33. Findings include: The facility's Enteral Tube Feeding policy, revised 3/27/21, documents to elevate the head of bed to 30 to 45 degrees. This form also documents to verify the placement of the feeding tube and gastric residual volumes per physician orders or as needed. On 4/04/22 at 11:30 AM, R32 was lying flat in the bed, not at a 30-45 degree angle. V4, Licensed Practical Nurse/LPN, washed V4's hands, put on gloves, and filled a plastic cylinder with 150ml (milliliters) of water. V4 opened the end of R32's G-tube (gastrointestinal tube), inserted the 60ml syringe into the gastrointestinal tube, flushed R32's G-tube with 150ml of water, then closed the G-tube and secured it in place. V4 stated V4 has not assessed R32's G-tube since V4's shift has started. V4 verified V4 did not check for placement or check for residual prior…

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 document diagnoses for the use of antipsychotic medications, failed to document and track target behaviors for the use of antipsychotic medications and failed to ensure residents exhibited behaviors that warrant the use of an antipsychotic medication for three of three residents (R24, R25, R52) reviewed for antipsychotic medications in the sample of 33. Findings include: 1. R52's current computerized Physician Orders, document R52 receives Seroquel (Antipsychotic) 25 mg (milligrams) three tablets (75 mg total) by mouth at bedtime Monday through Saturday (omitting Sunday). R52's Behavior Tracking forms, dated 11/1/21 through 4/30/22, document R52 has not had any behavior to justify the use of an antipsychotic medication. R52's Behavior Tracking forms, dated 11/1/21 through 4/30/22, do not document what R52's target behaviors are. R52's Minimum Data Set assessment, dated 3/10/22, documents R52 has severely impaired cognition, has daily…

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 as ordered by the physician for one resident (R41) on the sample of three residents reviewed for medication pass. This failure resulted in four medication errors out of thirty three opportunities, for a 12.12% medication error rate. FINDINGS INCLUDE: R41's current Physician Order Sheet, dated April 2022, includes the following medications: Metoprolol 50 MG take one tablet with or immediately after food; Potassium Chloride 10 MEQ (Milliequivalents) ER (Extended Release) take one capsule with food; Albuterol two puffs, shake well and wait 1 minute between puffs; and Folic Acid 1 MG take one tablet daily due to Anemia. On 4/3/22 at 7:34 AM, V3/Licensed Practical Nurse (LPN) prepared to administer medications for R41. V3, LPN placed one tablet of Metoprolol and one capsule of Potassium Chloride into a plastic cup, grabbed R41's Albuterol Inhaler, and entered R41's room. R41 was laying in bed sleeping. At that time, V3/LPN handed the plastic cup of medications to R4 along with a cup 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a physician's ordered diet for one of two residents (R330), reviewed for specialized diets, in a sample of 33 . R330's facility admission Record documents R330 was admitted to the facility on [DATE] from a local hospital with the following diagnoses: Fracture of the Left Hip and Pneumonitis due to Inhalation of Food. R330's admission Speech Therapy Treatment Note, dated 4/1/22, documents, Risk for aspiration with thin liquids. Currently receiving antibiotics for aspiration pneumonia. Continue Pureed diet with thickened liquids. R330's Nursing admission Assessment, dated 4/1/22, documents: Section G. Nutrition/Oral Status: No special needs or considerations. R330's admission Care Plan, dated 4/1/22, includes the following Focus and Interventions: Resident DIET IS GENERAL/REGULAR/REGULAR LIQUIDS. On 4/3/22 at 8:45 AM, R330 was sitting up in bed with R330's breakfast tray in front of R330. Two small plastic glasses, containing a thin…

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.