Sunset Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters for 10 of 10 residents (R1, R6, R20, R29, R49, R50, R54, R73, R81, and R143) reviewed for EBP in the sample of 36. Findings include: The facility's EBP (Enhanced Barrier Precaution) policy, undated, documents Policy Statement: EBPs are utilized to prevent the spread of MDROs (multi-drug resistant organisms) to residents. Policy Interpretation and Implementation: 1. EBPs are used as an infection prevention and control intervention to reduce the spread of (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. PPE (Personal Protective Equipment) is changed before caring for another resident. C. Face…

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 call lights were placed within reach for three of 18 residents (R30, R37, and R64) reviewed for accommodation of needs in the sample of 36. Findings include: The Call Light Policy (undated) documents All residents of (the facility) should have a working and reachable call light. Call Lights are available for residents to request assistance for a wide variety of reasons. Call lights are to be placed within reach no matter where the resident is located in their rooms. Examples of where call lights can be placed include clipped to the recliner, clipped around side rails (if the resident uses them), placed over bedside table as long as bed side table is in reach of the resident. 1. R37's MDS (Minimum Data Set) assessment dated [DATE] documents R37 is severely cognitively impaired, requires staff assistance for activities of daily living, and has a high risk for falls. On 10/22/24 from 9:45 AM through 10:40 AM R37 was lying in bed on her…

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

Based on Observation, Interview and Record review the facility failed to ensure a physician ordered hand splint was in place daily and a resident's limitations in range of motion were care planned for one of two residents (R73) reviewed for limitations in range of motion in the sample of 36. Findings include: The facility's (undated) Rehabilitation/Restorative Programs policy documents Upon admission or onset of a decline in Activities of Daily Living functions, a resident will be evaluated for individual status, and as potential candidate for Rehabilitation/Restorative program developed specifically for that individual. The goal/approaches of the individual's care plan shall be re-evaluated at least quarterly for any necessary revisions or modifications. R73's Minimum Data Set assessment, dated 9/4/24, documents R73 has Range of Motion impairments on one side for both upper and lower extremities. R73's Physician Order Sheet, dated 10/22/24, documents Patient to wear left upper extremity splint during daytime hours. Splint wear schedule: Donn (apply) with AM (morning) care, can wear…

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 with a diagnosis of Dementia and a history of falling was adequately supervised to prevent a fall for one of three residents (R51) reviewed for Falls in the sample of 36. Findings include: The facility's Falls Management Program policy, dated 7/21/23, documents Fall prevention takes a combination of medical treatment, rehabilitation, and environment changes. Prevention tools may include assessments, education, medication reviews, environmental changes, and the use of fall mats and alarms. In order to maintain a successful falls prevention program, all staff members are responsible for seeking out, removing, and reporting potential fall hazards. This policy also documents Psychotropic Drugs: Know which residents take a benzodiazepine (antianxiety medication) or an antipsychotic (medication). Watch residents who are on these drugs for side effects such as confusion, drowsiness, dizziness, changes in gait (walking), loss of balance, and changes in mental status. On 10/21/24 at 11:30 AM R51 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 ensure an indwelling urinary catheter drainage bag was covered for one of one resident (R6) reviewed for indwelling urinary catheters in a sample of 36. Findings include: The Catheter Care Procedure (undated) documents Performed By: Licensed Staff, CNA (Certified Nursing Assistant). Procedure: 16. Be sure catheter drainage bag is inside a cloth dignity bag and catheter tubing and dignity bag is not touching the floor. R6's current care plan documents the following, (R6) has a supra pubic urinary catheter. On 10/21/24 at 10:13 AM R6 was sitting in his room in his wheelchair. R6's catheter bag was secured to the bottom of his wheelchair with no privacy bag covering R6's urinary catheter drainage bag. On 10/21/24 at 11:10 AM R6 was sitting across from the fourth unit nursing station in his wheelchair. R6's catheter drainage bag was secured to the bottom of his wheelchair with no privacy bag. On 10/21/24 at 11:13 AM V5/Agency Licensed Practical Nurse verified R6's urinary catheter drainage bag was uncovered with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow a physician order for a daily weight for one of one resident (R45) reviewed for dialysis in the sample of 36. Findings include: The policy for Residents Receiving Hemodialysis (undated) documents Residents receiving dialysis will be weighed daily. Increases in weight will be monitored and reported as appropriate. R45's current computerized medical record, documents R45 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease, Heart Failure, and Hypertensive Heart Disease with Heart Failure. R45's MDS (Minimum Data Set) dated 8/14/24 documents a BIMS (Brief Interview for Mental Status) Score of 15/15, indicating (cognitively intact). R45's Care Plan documents that R45 receives hemodialysis related to End Stage Renal Disease. Obtain weight daily. R45's Physician Order documents to weigh daily and call physician 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to document behaviors and diagnoses to justify the use of antipsychotic medications, perform psychotropic assessments quarterly, and perform gradual dose reductions of scheduled antipsychotic medications for two of three residents (R37 and R51) reviewed for the use of anti-psychotic medications with the diagnosis of Dementia in the sample of 36. Findings include: The Psychotropic Drug Use policy (undated) documents A psychotropic drug is any that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: a) Anti-psychotic Psychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed. Psychotropic medications will be prescribed at the lowest possible dosage for the shortest…

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 document and address a grievance for one resident (R3) of three reviewed for resolution of grievances in the sample of seven. Findings Include: The Facility's undated Grievance/Concern Policy documents the purpose of the policy is to provide an opportunity for residents and/or family to present concerns or grievance to the proper authorities at the facility and to receive responses to the issues raised. The Grievance/Concern policy documents, It is the responsibility of the Department Directors to follow-up on the concerns and to ensure appropriate resolution. A copy of Concerns Forms must be sent to the Administrator for signature. Complaints may be presented to any staff member who should then report the issue to his/her supervisor and/or Social Services as soon as possible. Social Services will be responsible for completing the necessary documentation and to follow up with the resident and/or resident representative to assure a resolution. Social Services will maintain the Concern/Grievance Log. The Concern/Grievance…

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 wound assessment documentation and perform wound care for (R4) and failed to provide thickened water in between meals for (R3 and R7) for three of three residents (R3, R4, and R7) reviewed for quality of care in the sample of seven. Findings Include: 1. The Facility's undated Skin Care Ulcers policy documents good skin care is important to maintain good health and prevent pressure areas. The integrity of skin should be maintained as the first line of defense against infections and pressure ulcers. Documentation will be done on all types of skin ulcers. Licensed staff and CNA will be responsible for providing nursing interventions for those residents with ulcers. Treatments for all ulcers will be ordered by the Physician. Licensed staff will be responsible for providing the treatment ordered by the physician. R4's current MDS (Minimum Data Set) Assessment documents R4's BIMS (Brief Interview for Mental Status) score as 15 out of 15, indicating R4 is cognitively intact. R4's Physician Order Sheet for…

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

Based on record review and interview, the facility failed to obtain physician orders for treatment of a pressure ulcer wound in a timely manner and failed to document weekly pressure ulcer wound assessments for one of three residents (R3) reviewed for wounds in the sample of seven. Findings Include: The Facility's undated Skin Care/Ulcers policy documents Good skin care is important in order to maintain good health and prevent pressure area. The integrity of the skin should be maintained as the first line of defense against infections and pressure ulcers. Documentation will be done on all types of skin ulcers. The unit coordinator will document when and where the ulcer developed, and interventions used in the nursing notes. The condition of the area including size, appearance, drainage, odor and progress will be documented on the weekly pressure ulcer healing assessment on a weekly basis using the following guidelines. 1. Be specific with the location of the wound. 2. Note the condition of the skin around the area 3. Note the size of the wound. Measure accurately. If unable to…

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

Based on interview and record review staff failed to immediately notify the Administrator of possible abuse of one resident (R1) of three residents reviewed for abuse in the sample of three. Findings include: The Abuse and Neglect Policy dated July 2023, documents It is the policy of (the facility) to provide each resident with an environment free from abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of resident property, exploitation and physical or chemical restraint not required to treat the residents' symptoms, as defined below. (The facility) shall follow the procedure for reporting and investigation of alleged resident abuse and neglect as outlined below, and in accordance with Skilled Nursing and Intermediate Care Facilities Code. The purpose and scope of this policy and procedure is to inform all individuals of the proper protocol for preventing, reporting, and investigating allegations of abuse and neglect, as specified in the corporate policy above. It is the responsibility of all employees, consultants, attending physicians, family members,…

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 notify the physician of a resident's (R1's) significant decline in condition and of a resident (R2) not receiving a physician ordered IV (Intravenous) antibiotic medication for two of three residents (R1 and R2) reviewed for notification of changes in the sample of six. Findings include: The facility's Change in a Resident's Condition or Status policy (undated) documents, Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and or status. 1. The nurse supervisor will notify the resident's attending physician or on-call physician in a timely manner when there has been: d. A significant change in the resident's physical/emotional/mental condition. e. A need to alter the resident's medical treatment significantly. f. Refusal of treatment or medications (two or more consecutive times). g. A need to transfer the resident to a hospital/treatment center. 2. A significant change of condition is a decline or improvement 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Facility failures resulted in two deficient practices. A. Based on record review and interview the facility failed to document and assess for an underlying condition and seek medical treatment after a significant change in status for over 24 hours for one of three (R1) residents reviewed for timely care after a change in status in the sample of six. B. Based on record review and interview the facility the facility failed to perform a treatment to a diabetic heel ulcer as ordered by the physician for one of three residents (R2) reviewed for altered skin conditions in the sample of six. Findings include: A. The facility's Change in a Resident's Condition or Status policy (undated) documents, Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and or status. 1. The nurse supervisor will notify the resident's attending physician or on-call physician in a timely manner when there has been: d. A significant change in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to infuse a physician ordered IV (Intravenous) antibiotic as ordered for one of three residents (R2) reviewed for significant medication errors in the sample of six. Findings include: The facility's (undated) Medications Errors policy documents All medication errors will be documented on a medication error report and given to the charge nurse on duty at the time the error was found. Some examples of medication errors would be: 4. Medication not given at appropriate time. R2's BIMS (Brief Interview of Mental Status) dated 11-22-23 documents R2 is cognitively intact. R2's Progress Notes dated 11-29-23 document R2 was discharged to home. R2's Progress Notes dated 8-16-23 document R2 was admitted to the facility with diabetic wound ulcer to the right heel. R2's Progress Notes dated 8-17-23 document R2 was admitted to the facility on [DATE] after being treated at the hospital for a diabetic wound ulcer with osteomyelitis (bone infection) to the right…

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 disinfectant used on all food preparation surfaces and all dining room tables were within the proper concentration perimeters. This failure has the potential to affect all 94 residents within the facility. Findings include: The facility's Daily Census Sheet dated 11-13-23 documents 94 residents currently reside within the facility. The facility's Sanitization policy dated 08/2008 documents, All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Sanitizing of environmental surfaces must be performed with one of the following solutions: a. 50-100 ppm (parts per million) chlorine solution. b. 150-200 ppm quaternary ammonium compound (QAC). c. 12.5 ppm iodine solution. Between uses, cloths and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution will be changed at least…

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 develop a comprehensive care plan for an indwelling urinary catheter, prophylactic antibiotic, the use of insulin, the use of an anticoagulant, and bowel/bladder incontinence for 6 of 22 residents (R8, R21, R27, R44, R45, R91) reviewed for care plans in the sample of 67. Findings include: The facility's Care Plan Procedure, no date available, documents, The Interdisciplinary Team will review the attending physician's order (e.g., dietary needs, medications, and routine treatment, etc.), and implement a nursing care plan to meet the resident's immediate care needs. An individualized comprehensive care plan that includes measurable objectives and timeline to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning 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 measure potential zones of entrapment for 54 of 54 residents (R1, R3, R4, R5, R7, R8, R10, R11, R19, R21, R23, R24, R25, R27, R28, R30, R36, R37, R38, R39, R40, R41, R43, R44, R45, R47, R52, R58, R59, R60, R61, R62, R64, R66, R68, R69, R70, R71, R76, R78, R79, R80, R82, R83, R85, R86, R87, R89, R91, R93, R95, R153, R154, R155) reviewed for siderails in the sample of 67. Findings include: The facility's Bed Safety Policy (undated) documents, Policy Statement: Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation 2. To try to prevent death/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment quarterly as part of our regular bed safety program to identify risks and problems including potential entrapment risks. b. Review that gaps within the bed…

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

Based on interview and record review the facility failed to allow choices for one resident (R79) of nineteen residents reviewed for choices in a total sample of 67. Findings Include: The undated Illinois Long-Term Care Ombudsman Resident's Rights booklet documents Your facility must be safe, clean, comfortable and homelike and You may keep or use your own property, R79's Progress Notes dated 11/07/23 at 1:29 PM documents (R79) wants own curtains that are Viking sport themed, and others taken down. Explained to him that due to regulations and privacy, etcetera this was not allowable. He did call his mother and she called me. I did check other staff to make sure I wasn't necessarily mistaken and then explained it to her about regulations but said she understood. I did go back and talk the (R79) again and this time said he understood. On 11/13/23 at 8:00 AM R79 stated My mom wanted to get me curtains for my room, but they told her no that the state doesn't allow that. I can understand (the privacy curtain) because not everyone likes the same sports, but she even said no to the window…

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 deliver cares in a dignified manner for one resident (R74) during a routine tour of the building in a total sample of 67. Findings Include: The Facility's undated Cell Phone Use Policy documents Employees may use cell phone/ electronic communication devices during lunch or break periods or as authorized in private space away from all patient care area and common work areas. Other than described, personal cell phones/electronic communication devices are to be turned off and stored during working hours and are not to be kept on person, in patient treatment areas or nursing stations unless authorized. On 11/16/23 at 10:30 AM V23 (Certified Nurse Aide) could be overheard speaking No, I told her to quit calling me about your business I don't want to be involved. Then V23 turned the corner and was observed on her cell phone in her left hand, with one hand loosely under the gait belt around R74. When V23 saw this surveyor, she immediately hung-up mid-sentence and began asking the resident how her day has been. 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 record review and interview the facility failed to formulate Advance Directives for one resident (R203) of 19 reviewed for Advanced Directives in a total sample of 67. Findings Include: The Facility's Statement of Facility Policy Regarding Advanced Directives and Life-Sustaining Treatment documents Federal law requires (this facility), as well as other health care facilities participating in certain federal programs, to distribute information regarding the right of adults to participate in medical treatment decisions. It is the policy of (the facility) to comply with Illinois court decisions and statutes regarding individual surrogate participation in medical treatment decisions and implementation of Advanced Directives. R203's medical record did not contain any information regarding whether the resident wished to be a full code or a do not resuscitate. On 11/14/23 V26 (Licensed Practical Nurse) confirmed that there was no advance directive information in R203's medical record. V26 stated that information is usually on the banner of the electronic medical record, on 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.

Based on observation, interview, and record review, the facility failed to ensure a resident's room was free of urine odors for one of one resident (R44) reviewed for ADL (Activities of Daily Living) in the sample of 67. Findings include: R44's MDS (Minimum Data Set), dated 10/25/23, documents in Section H Bladder and Bowel that R44 is always incontinent of urine and occasionally incontinent of her bowels. On 11/13/23 at 07:26 a.m., R44 was alert reclined in her recliner in her room. R44's room had a foul significant urine odor. On 11/16/23 at 10:45 a.m., R44's room had a foul urine odor. On 11/16/23 at 11:15 a.m., V9 (Unit Coordinator) stated, (R44) is occasionally incontinent of urine, and the staff should be assisting her with that care as needed. I'm not sure why her room would smell of urine, but it shouldn't. On 11/16/23 at 11:30 a.m. V24 (Housekeeper) was standing outside of R44's room. V24 confirmed that R44's room had a strong urine smell. On 11/16/23 at 11:32 a.m. V25 (Licensed Practical Nurse), stated, (R44) is incontinent of urine a lot, and her room smells like urine…

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 one allegation of neglect for one resident (R79) of one reviewed for abuse in a total sample of 67. Findings Include: The Facility's undated Abuse and Neglect Policy documents It is the policy of (this facility) to provide each resident with an environment free from abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of resident property, exploitation and physical or chemical restraint not required to treat the residents' symptoms, as defined below. (This facility) shall follow the procedure for reporting and investigation of alleged resident abuse and neglect as outlined. The Facility's undated Abuse and Neglect Policy defines neglect refers to the failure to provide goods and/or services necessary to avoid physical harm, mental anguish, or mental illness. The Facility's undated Abuse and Neglect Policy documents It is the responsibility of all employees, consultants, attending physicians, family members, visitors, etc., to immediately report any incident, suspected incident, or allegation…

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 wear gloves while cleansing a diabetic ulcer and perform hand hygiene during wound care for one of one resident (R47) reviewed for diabetic ulcers in the sample of 67. Findings include: The facility's Handwashing/Hand Hygiene policy, no date available, documents, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents and visitors. Employees must wash their hands for at least fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: After handling soiled or used linens, dressings, bedpans, catheters, and urinals; After removing gloves. When to use Alcohol-Based hand rub: Before moving from a contaminated body site to a clean body site during resident care; After handling used dressings, contaminated equipment, etc; After removing gloves. The facility's Dressings, Soiled/Contaminated policy, no…

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, observation, and record review the facility failed to document a diagnosis to warrant the use of an indwelling urinary catheter, ensure an indwelling urinary catheter drainage bag was kept below the level of the bladder and off of the floor, secure indwelling urinary catheter tubing, and complete a scheduled urinary catheter change for three of five residents (R27, R71, R91) reviewed for indwelling urinary catheters in the sample of 67. Findings include: The facility's Catheter and Incontinence Care Management Policy (undated) documents, Policy: In accordance with regulatory requirements and professional practice standards, the facility will ensure that: 1. A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrations that catheterization is necessary; justification. Appropriate indications for continuing use of an indwelling catheter beyond 14 days may include i. Urinary retention that cannot be treated 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 ensure a nebulizer mask and nebulizer tubing was dated and stored in a bag between uses for one of two residents (R40) reviewed for respiratory care in a sample of 67. Findings include: The facility's Nebulizer Administration Policy (undated) documents, Nebulizer Administration: When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Change equipment and tubing every seven days, or according to the facility protocol. R40's current POS (Physician Order Sheet) documents an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg(milligram)/3 ml(milliliter) one vial inhale orally four times a day and every four hours PRN (as needed). On 11/13/2023 at 7:50 AM R40's nebulizer tubing and nebulizer mask were laying on R40's floor un-bagged and undated. On 11/13/23 at 8:40 AM V9 RN (Registered Nurse) confirmed R40's nebulizer tubing and nebulizer mask were undated and un-bagged. V9 stated, Nebulizer masks and nebulizer tubing should be put in a plastic bag 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 interview and record review, the facility failed to develop a Dementia plan of care for one of three residents (R8) reviewed for Dementia in the sample of 67. Findings include: The facility's Care Plan Procedure, no date available, documents, The Interdisciplinary Team will review the attending physician's order (e.g., dietary needs, medications, and routine treatment, etc.), and implement a nursing care plan to meet the resident's immediate care needs. An individualized comprehensive care plan that includes measurable objectives and timeline to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. R8's Medication Review Report, dated 11/14/23, documents that R8 has a diagnosis of unspecified Dementia. R8's Current Care plan, provided 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 document a diagnosis and behaviors to warrant the use of an antipsychotic, ensure a resident was free of dual psychotropic medication therapy, obtain an informed consent for the use of a psychotropic, and obtain a stop physician order for a PRN (as needed) psychotropic medication for three of five residents (R28, R45, R79) reviewed for psychotropics in the sample of 67. Findings include: The facility's Psychotropic Drug Use policy, no date available, documents, Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the residents and others. Diagnoses alone do not warrant the use of psychotropic medications. In addition to the above criteria, psychotropic medications will generally only be considered if the following conditions are met: The behavioral…

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 an opened multi-dose diabetic insulin pen was labeled with the date opened for one of 67 residents (R2) reviewed for storage and labeling of medications in a sample of 67. Findings include: The facility's Administering Medications policy (undated) documents, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. When opening a multi-dose container, the date opened shall be recorded on the container. Date opened will be recorded on the pen (insulin pen). On 11/14/23 at 9:25 AM V14 (RN/Registered Nurse) was standing at the medication cart passing medications on her hallway. V14 opened the top drawer of the medication cart where residents' vials of opened insulin injector-pens were stored. In this drawer R2's Humalog 100 units/ml (milliliter) insulin multi-dose pen was open and without a label indicating the date opened. V14 verified R2's insulin pen had no label with the date opened. On 11/14/23 at 11:30 AM V2 (Director of Nursing) stated, All insulin pens…

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 wash their hands and to transport linen in an effective manner to avoid contaminating items for three residents (R27, R38 and R91) in a total sample of 67. Findings Include: The Facility's undated Handwashing Policy documents This facility considers handwashing the primary means to prevent the spread of infections. The Facility's Handwashing Policy also documents All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, and visitors. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions. B. when hands are visibly soiled (hand washing with soap and water. C. before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice. H. Before and after assisting a resident with personal care (e.g., oral care, bathing.) N. Before and after assisting a resident with toileting (hand washing with soap 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 interview and record review the facility failed to complete a comprehensive care plan addressing Hospice care for one of one resident (R56) reviewed for hospice in a sample of 29. Findings include: The facility's Care Plans-Comprehensive Policy undated, documents, An individual comprehensive care plan that includes measurable objective and timetables to meet the resident's medical nursing, mental and psychological needs is developed for each resident. Assessments of resident's are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition, b. When the desired outcome is not met, c. When the resident has been readmitted to the facility from a hospital stay, and d. At least quarterly. R56's current POS/Physician Order Sheet documents, 10/10/22, admitted to Hospice. On 10/27/22, R56's current Comprehensive plan of care did not address Hospice care with…

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 revise care plans to address locations of pressure ulcers, pressure ulcer preventive measures or fall prevention interventions for two of 18 residents (R86, R87) reviewed for care plans in a sample of 29. Findings include: The facility's Care Plans-Comprehensive Policy undated, documents, An individual comprehensive care plan that includes measurable objective and timetables to meet the resident's medical nursing, mental and psychological needs is developed for each resident. Assessments of resident's are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition, b. When the desired outcome is not met, c. When the resident has been readmitted to the facility from a hospital stay, and d. At least quarterly. 1. R86's current care plan, dated as last reviewed 8/21/22, documents, I had an actual…

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 perform pressure ulcer risk assessments, accurately assess pressure wounds, develop, and implement individualized pressure ulcer prevention interventions based on pressure ulcer risk, or have a consistent method for tracking the improvement or decline of pressure ulcers for one of three residents (R86) reviewed for pressure ulcers in a sample of 29. Findings include: A Pressure Ulcer Prevention Policy and Procedure (undated) states, Health(y), intact skin will be promoted. and Visually assess all bony prominences (heels, ankles, hips, sacrum, occiput, ears, shoulders, elbows) at least daily, and Assess mobility and activity. This policy states, Reduce or eliminate pressure, shear, friction, and moisture, and prevent skin breakdown. In addition, this policy states that interventions to prevent pressure ulcers should include, Use devices such as pillows or padding to prevent direct contact between bony prominences, and Relieve pressure to…

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

Based on observation, interview and record review the facility failed to ensure a resident prescribed antipsychotic medications was assessed for clinical indications for use, appropriate diagnoses, and adverse target behaviors to warrant the use of antipsychotic medications for two of five residents (R49, R73) reviewed for unnecessary medications in a sample of 29. Findings include: A Psychotropic Drug Use policy (undated) states, A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. This policy states that psychotropic drugs include Antipsychotic medications. In addition, this policy states, Psychotropic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, 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 ensure a resident received the correct dosage of Keppra (anticonvulsant medication) and complete a medication error report for the 65 wrong dose administrations for one of 24 residents (R62) reviewed for medications in the sample of 29. Findings include: The facility's Medication Errors policy, dated 3/3/04, documents All medication errors will be documented on a Medication Error Report and given to the charge nurse on duty at the time the error was found. The nurse discovering the error fills out the Incident Report of Medication Error Report. Some examples of medication errors would be: Improper amount of medication given to a resident. The facility's (undated) Administering Medications documents Medications shall be administered in a safe and timely manner and as prescribed. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, 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.