La Bella of Rochelle

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an allegation of abuse between two residents to the state agency when R1 hit R2. This failure affects two of four residents (R1/R2)reviewed for abuse in the sample of six.The findings include:The written Statement from Administrator dated 10/20/25 in an investigation file for R1 & R2 showed, On October 20th, during a conference call around noon, the writer was informed of a confrontation between two residents, R2 and R1 both with a BIMS (Brief Interview of Mental Status) of 15 (no cognitive impairment). R2 reported that she entered R1's room without a clear reason, which R1 found objectionable. Following this, R1 confronted R2 in her own room. R1 claimed that R2 was going through her personal belongings, which did she did not appreciate. At the time of these interviews, there was no evidence or confirmation of physical contact or altercation between the two. The Medical Doctor was notified, and the Power of Attorney (POA) was contacted. 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 medications were administered within their scheduled timeframe for 1 of 1 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's facesheet showed she was admitted to the facility 9/18/19 with diagnoses to include transient cerebral ischemic attack, pseudobulbar affect, disorders of bone density and structure, major depressive disorder, spastic hemiplegia, insomnia, bipolar disorder, hyperlipidemia, mood disorder, and anxiety disorder. On 7/1/25 at 10:36 AM, V4 RN (Registered Nurse) was administering medications to R1. V4 said, These are [R1's] scheduled morning medications. V4 said she has been really busy this morning with a resident who is 1 on 1 at the nursing station. R1's July 2025 eMAR (electronic Medication Administration Record) showed medications scheduled to be administered at 7:00 AM to include dicyclomine 10 mg (milligrams) TID (three times a day), gabapentin 600 mg TID, Hydrocodone-Acetaminaphen 10-325 mg TID, and Metformin HCL 1000 MG BID (two times a day).…

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 residents were allowed to smoke for 17 of 19 residents (R1 and R3-R18) reviewed for resident rights in the sample of 19. The findings include: On 6/17/25 the facility provided list of residents that smoke which included R1 and R3-R18. On 6/17/25 at 9:15 AM, R15 stated she was told by facility staff on Friday (6/13/25) that the 5:30 PM smoke break was going to be discontinued starting the following Monday (6/16/25). R15 said all the smokers were told on Friday but they would still have the weekend to get a 5:30 PM smoke break. R15 said none of the smokers got to go outside at 5:30 PM on Saturday because there was no one to take them outside. On 6/17/25 at 9:28 AM, R3 said over the weekend the 5:30 PM smoke break was taken away. R3 said she was seated outside on the patio on Saturday. It was after dinner and she was not allowed to smoke. R3 said she heard two male residents yelling just inside the door. It was something about not being able to smoke. R3 said she was told the 5:30 PM smoke break would continue over 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 ensure a residents (R1 & R2) were free from physical abuse for two residents reviewed for abuse in the sample of 19. The findings include: On 6/17/2025 at 9:17 AM, R2 was sitting in the activity/sitting area watching television. R2 did not understand this surveyor's questions due to R2 mostly speaking Spanish. V11 (Certified Nursing Assistant-CNA) translated for this surveyor and R2. R2 was asked about the incident with another male resident a few days prior. R2 said R1 was walking from the back hall. R2 said he (R2) got up to go over to the table across the room. R1 pointed to him to go over there, (like get moving), then R1 hit him (R2) in the shoulder and made him hit his head on the wall. R2 said they sent him to the hospital to check him out. He does not think he had any injuries. R2 said R1 hit him at least 3 times. R2 pointed to each area his left lower arm, upper left arm, and his right shoulder. R2 said he swung back at R1, but R1 was the one that started it. R2 said he feels safe in the facility;…

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

Based on observation, interview and record review the facility failed to employee a qualified dietary staff member to oversee the operations of the kitchen. The facility failed to ensure residents' nutritional assessments were completed, in-person, by a qualified dietary staff member. These failures have the potential to affect all 51 residents in the facility. The findings include: The Facility Data Sheet dated 5/5/25 showed 51 residents resided in the facility. A facility list dated 5/5/25 showed V3 Dietary Manager was hired as the facility's dietary manager on 7/1/23. On 5/5/25 at 7:47 AM, V3 Dietary Manager and V4 Dietary Aide were the only kitchen staff, in the building, preparing and plating breakfast trays for the residents. On 5/5/25 at 8:26 AM, V3 Dietary Manager stated she had never received her certification in dietary management or food service. V3 stated she had taken the online dietary management course three times but was unsuccessful at passing the certification test. V3 stated she had never enrolled in any college courses. V3 stated no staff member in the facility…

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

Based on observation, interview and record review the facility failed to provide sufficient dietary staff to carry out the necessary functions of the food service. The facility failed to ensure dietary staff had the required certifications to provide food service to residents. These failures have the potential to affect all 51 residents in the facility. The findings include: The Facility Data Sheet dated 5/5/25 showed 51 residents resided in the facility. A facility list dated 5/5/25 showed V3 Dietary Manager was hired as the facility's dietary manager on 7/1/23. The list showed the following hire dates for all kitchen/dietary staff: V4 Dietary Aide on 3/16/22 V6 [NAME] on 7/3/23 V7 [NAME] on 3/3/25 V8 Dietary Aide on 7/11/24 V9 [NAME] on 10/21/15 On 5/5/25 at 7:47 AM, V3 Dietary Manager and V4 Dietary Aide were the only kitchen staff, in the building, preparing and plating breakfast trays for the residents. V3 placed each resident's food on Styrofoam plates and/or bowls. V3 stated, We are using paper plates for breakfast because my cook didn't show up this morning. I don't have…

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

Based on observation, interview and record review the facility failed to ensure a breakfast menu was followed. This failure has the potential to affect all 51 residents in the facility. The findings include: The Facility Data Sheet dated 5/5/25 showed 51 residents resided in the facility. The facility's breakfast menu dated 5/5/25 showed the following menu of hot or cold cereal, scrambled eggs, (1) Danish roll, mandarin oranges, milk, and assorted juices. On 5/5/25 at 7:47 AM-8:20 AM, V3 Dietary Manager and V4 Dietary Aide were the only kitchen staff, in the building, preparing and plating breakfast trays for the residents. V3 Dietary Manager placed the food on plates as V4 served the prepared plates to the residents in the dining room. No mandarin oranges were served to any residents. No mandarin oranges were noted on the prep tray as an option to serve to residents. On 5/5/25 at 9:27 AM, V3 Dietary Manager stated mandarin oranges were not served to any residents at breakfast because she forgot they were on the menu. On 5/5/25 at 2:50 PM, V2 Director of Nursing stated the facility…

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

Based on observation, interview, and record review the facility failed to ensure the prescribed wound treatment was provided to a resident with stage 4 pressure ulcer. This applies to 1 of 3 (R4) residents reviewed for wounds in the sample of 5. The findings include: On 4/14/25 at 10:55 AM, R4 was observed lying in bed. On 4/14/25 at 10:24 AM, V2 (DON) said she was informed R4's packing strips for his wound treatment were running low on Thursday (4/10/25). She placed the order for the gauze packing strips (iodoform) and deliveries come on Thursday. She asked V4 (Wound Nurse) the wound nurse to call the physician to obtain new orders to pack the wound. V2 said she does not know if V4 obtained new treatment orders and they do not have an inventory process for supplies. On 4/14/25 at 10:52 AM, V4 (Wound Nurse) said the floor nurses provide the wound treatments and she rounds with the wound physician. V4 said they have packing strips for R4's wound. This surveyor and V4 checked the wound treatment cart. The treatment cart did not not have R4's gauze packing strips (iodoform). V4 checked…

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 physical therapy treatments for a resident admitted for skilled services. This applies to 1 of 3 (R1) residents reviewed for rehab services in the sample of 5. The findings include: R1's face sheet shows he is a [AGE] year old male admitted on [DATE], with diagnoses including embolism and thrombosis of the lower extremities, chronic atrial fibrillation, diabetes mellitus, hypertension, COPD, CHF, and peripheral vascular disease. On 4/14/25 at 8:46 AM, R1 was observed sitting in his wheelchair with mechanical lift sling under him. R1 said they transfer him using the mechanical lift. R1 said his right leg is weak and he can stand but is not ambulating. R1 said get me the hell out of here. R1 said he's been here for about one month and is not receiving physical therapy five days a week. R1 said he has Medicare A they cover 120 days of skilled care. R1 said he came to the facility after having a blood clot in his right leg and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place, and failed to identify and implement a system to ensure bed and chair alarms are functioning. These failures apply to 1 of 3 residents (R1) reviewed for falls in the sample of 4. The findings include: R1's face sheet printed on 4/8/25 showed R1 has diagnoses including but not limited to schizophrenia, anxiety disorder, dementia without behaviors, extrapyramidal & movement disorder, bipolar disorder, and unsteadiness on feet. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment and has experienced 2 falls without injury and 1 fall with injury. R1's fall risk assessment dated [DATE] (prior to R1's most recent fall) showed R1 is a high fall risk. R1's care plan dated 4/22/24 showed, (R1's) review shows risk for falls. Risk Factors include behavior- impulsive without regard for safety, cognitive Impairment- does not understand limits, gait/balance problems . 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 provide medical records to a resident's guardian/power of attorney for healthcare (POA) upon verbal and written request for 1 of 3 residents (R1) reviewed for the right to access medical records in the sample of 3. The findings include: A Letters of Guardianship form dated 9/30/2020 showed V6 was appointed R1's legal guardian. A Power of Attorney for Healthcare (POA) form dated 4/15/2015 showed V6 was appointed R1's POA. R1's current care plan showed R1 was cognitively impaired related to her diagnoses of mild intellectual disability, bipolar disorder, and schizophrenia. On 3/24/25 at 4:44 PM, V6 (R1's Guardian/POA) stated she had been asking V1 Administrator for copies of (R1's) medical records for her restorative cares and oral cares for awhile now. At least since February (2025). V6 stated she asked V1 Administrator, via email in February 2025, to email her a release of information form for her to complete to request these medicals records but he never sent me one. V6 stated she again verbally requested copies of R1's…

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

Based on observation, interview, and record review the facility failed to ensure the dish machine was plumbed per code to prevent cross-contamination. This has the potential to effect all residents residing in the facility. The findings include: The Centers for Medicare and Medicaid form 671 dated 3/3/25 shows there are 49 residents residing in the facility. On 3/3/25 at 9:23 AM, two dietary aides were using the dish machine to clean dishes. V7 (Dietary Manager) grabbed the test strips to test the dish machine sanitizer concentration. When V7 was attempting to get the sanitizer concentration, this surveyor noticed the water in the sink to the left of the dish machine had backed up water that continued to rise with food debris floating in the water. The dish machine water level was also rising as the water in the sink rose. Observation of the plumbing for the sink and dish machine showed that the pipe coming from the dish machine for the dish machine waste water was plumbed in line with the adjacent sink with a garbage disposal attached to the sink and then the pipe ended in a grease…

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 track and trend resident illnesses failed to ensure the required PPE (Personal Protective Equipment) was worn when providing care to a resident on enhanced barrier precautions (EBP), and failed to ensure EBP signs were posted outside of residents' rooms. This failure has the potential to affect all 49 residents residing in the facility. The findings include: 1. The Facility's Resident Census and Conditions form dated March 3, 2025 shows the facility census was 49. The facility's Resident Illness Tracking and Trending Log was requested on March 4, 2025. There were no tracking and trending resident illnesses logs. On March 4, 2025 at 11:58 AM, V2 DON (Director of Nursing) and V3 Infection Control Preventionist said they did not have a way to track and trend resident illnesses. V2 and V3 said the only illnesses that are tracked are influenza, covid, and pneumonia. V2 DON said, I did not know I had to do that. 2. On 3/3/25 at 9:59 AM, R103's door to his room did not have an Enhanced Barrier Precautions (EBP) sign…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's advanced directive to be a full code was ordered for 1 of 18 residents (R103) reviewed for advanced directives in the sample of 18. The findings include: R103's Hospital Discharge summary dated [DATE] shows, Resuscitation Status at discharge: Full Code R103's Physician's Order Sheet printed on 3/4/25 shows an order dated 2/24/25 for DNR (Do not Resuscitate). On 3/4/25 at 1:00 PM, R103 said that he wants to be resuscitated. R103 stated, I am not sure where the talk about being a DNR came from, in the hospital, they almost lost me a couple times. On 3/4/25 at 12:01 PM, V3, Registered Nurse (RN) said that R103's hospital paperwork said DNR so she put the order in the computer. V3 said that she did not notify social services of the change because he came back very late from the hospital. On 3/4/25 at 1:33 PM, V9 (RN) said that in an emergency, she would determine a resident's code status by looking at the order in the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who is dependent on staff for Activities of Daily Living (ADLs) received incontinence care in a timely manner for 1 of 18 residents (R33) reviewed for ADLs in the sample of 18. The findings include: R33's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired, is dependent on staff for toilet hygiene and is incontinent of urine and stool. On 3/3/25 at 11:55 AM, V22 and V23, Certified Nursing Assistants (CNAs) provided incontinence care to R33. R33's incontinence brief was saturated with urine and stool. R33's buttock was reddened. R33's sheet and shirts were wet from urine. On 3/3/25 at 11:55 AM, V23 said that she last checked R33 around 6:20 AM and she was not wet so did not provide incontinence care to her. V23 said that R33 did not want to get up for breakfast so she let her stay in bed. V23 said that she did not have time to check her again until 11:45 AM. V23 said that she did not had time 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a cholecystostomy drain had a dressing order in place and failed to ensure ace wraps were applied for treatment of lower extremity edema as ordered for 2 of 18 residents (R40 and R103) reviewed for quality of care in the sample of 18. The findings include: 1. On 3/3/25 at 9:59 AM, V3 (Registered Nurse) changed a dressing to R103's cholecystostomy drain site. V3 said that he did not come back from the hospital with dressing orders for the drain but she has been doing it when she does his other dressing change to his abdominal wound. On 3/4/25 at 12:01 PM, V3 said that if a resident admits with a wound and no orders for dressing changes, the nurse should speak to the physician to obtain orders. V3 said that once the orders are received, they should be placed in the electronic medical record so the staff know when the dressing is supposed to be performed. V3 said that the nurse does the dressing changes based on the order. R40's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were in place for two of 18 residents (R28, R31) reviewed for safety in the sample of 18. The findings include: 1. R28's admission Records dated March 5, 2025 shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, depression, and acquired absence with right and left leg below the knee. R28's Fall assessment dated [DATE] shows he has a moderate risk of falling. On March 3, 2025 at 10:24 AM, R28 said he has been waiting for a better wheel chair from the facility for a long time. R28 said the locks on his wheel chair do not work. R28 said the wheel chair still moves. R28 said he is able to self transfer himself out of his bed into the wheel chair. R28 said he ended up on the floor one day because he was transferring himself from his bed into his wheel chair and the wheel chair rolled, I ended up on the floor. R28 placed the locks on his wheel chair and 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 on observation, interview and record review the facility failed to ensure medications were available and administered as ordered and failed to ensure residents were supervised while administering medications for 2 of 18 residents (R23, R49) reviewed for pharmacy services in the sample of 18. The findings include: 1.) R23's Medication Administration Summary and Physicians Order Summary (POS) both show R23 should receive Buspirone (anti-anxiety medication) 5 mg. (milligrams) at noon. On 3/3/25 at 12:20 PM during noon medication pass, V9 (Registered Nurse/ RN) was preparing medications for R23. There was no Buspirone in the medication cart so V9 checked in the convenience box in the medication room and was not able to find the medication. V9 said more then likely the medication is still on the way to the facility and had not yet arrived from the pharmacy. V9 said medications are considered on time if they are administered one hour before or after the scheduled time. On 3/3/25 at 1:45 PM, V9 verified with the surveyor that the medication had not come and she was not able 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 the facility failed to ensure monthly pharmacy recommendations were carried out. This applies to 1 of 5 residents (R31) reviewed for drug regimen reviews in the sample of 18. The findings include: R31's Facesheet dated 3/5/25 shows R31 has diagnoses including, but not limited to: cerebral palsy, major depressive disorder, epilepsy, anxiety, schizoaffective disorder, paraplegia, hypokalemia, gastro-esophageal reflux disease (GERD), hyperkalemia, encephalopathy, hypertension, and hyperlipidemia. R31's Consultation Report for R31's monthly medication regimen review dated 1/15/25 states, [R31] has not had an assessment of kidney function with the past 6 months. Please monitor a serum creatinine on the next convenient lab day and at least every 6 months thereafter. On 3/5/25 at 11:12 AM, V2 (Director of Nursing) was shown a copy of the monthly medication regimen review recommendation forms and V2 stated V2 has never seen it before and doesn't do anything with them. V2 indicated maybe V20 (Regional Nurse) might be following through with the monthly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain patient care equipment in safe operating condition for three of 18 residents (R28, R4, R19) reviewed for safe equipment in the sample of 18. The findings include: 1. R28's admission Records dated March 5, 2025 shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, depression, and acquired absence with right and left leg below the knee. On March 3, 2025 at 10:24 AM, R28 said he has been waiting for a better wheel chair from the facility for a long time. Look at this! The tires are coming off! The rubber on R28's wheels on his wheel chair was worn and pieces were missing. The rubber of the wheel was coming off of the metal wheel. R28 said the locks on his wheel chair do not work. R28 said the wheel chair still moves. R28 said he is able to self transfer himself out of his bed into the wheel chair. R28 said he ended up on the floor one day because he was transferring himself from his 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 protect a resident from mental abuse for one of four residents (R1) reviewed for abuse in the sample of 7. The findings include: The Face Sheet dated 1/22/25 for R1 showed diagnoses including major depressive disorder, anxiety disorder, autistic disorder, bipolar disorder, vitamin D deficiency, hyperlipidemia, hypothyroidism, and obesity. The Facility Incident Report Form - Final Report dated 1/13/25 showed, on 1/13/25, a nurse was notified by R1 that V4 CNA (Certified Nursing Assistant) and V5 CNA made her feel bad for two weeks. R1 stated she was ill a couple weeks ago, and V4 and V5 made her pick up the bedding after she became sick on the sheets. R1 stated, I had to clean up the vomit on the sheets, wall, and floor. Both CNAs told me I was on an independent hall and had to clean up after myself. Staff members involved were placed on suspension pending investigation. An investigation was immediately initiated. R1 was assessed head to toe and did not show any signs of obvious signs of physical, mental, or psychosocial…

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 facility has a fulltime Director of Nursing (DON). This failure affects all residents residing at the facility. The findings include: The Facility Data Sheet dated 12/9/24 show there are 52 residents residing in the facility. On 12/9/24 at 8:15 AM, both V4 (Registered Nurse/RN) and V5 (RN) said they have not had a DON since November 1, 2024 when the new company took over. Both V4 and V5 said they have just been calling (V1- Administrator) for any issues including nursing issues. Both V4 and V5 said the new company has a Nurse Consultant (V7) but (V7) had only been at the facility for maybe a couple of times since November 1, 2024. Both V4 and V5 were aware that V1 is not a nurse. At 8:25 AM, V6 (MDS/RN) said she was an RN but she was not the (DON) designee. V6 stated, No one has asked me to be the DON designee. The nurses are used to calling (V1-Administrator) for any issues, including nursing issues. On 10:10 AM, V1 (Administrator) said since the new corporation took over (November 1, 2024), the facility has had…

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 representative had access to the resident's medical records to 1 of 3 residents (R1) reviewed for medical record in the sample of 3. The findings include: On 12/9/24 at 9:30 AM, while this surveyor was at the facility with V1 (Administrator), V3 (R1's sister/guardian) was also at the facility and asked V1 (Administrator), Have you had a chance to get me a copy of (R1's) records about her bruise to her left forehead? V1 responded to V3, No I have not.I will have a nurse to do that for you. At 9:40 AM, V3 said this is the 3rd time she had requested access to R1's medical record from V1. On 11/29/24 when she discovered R1's bruise to the left side of R1's forehead, V3 said she asked V1 and the V4 (Registered Nurse/RN) what happened to R1. V3 said she worries when R1 has bruised her head since R1 was on a blood thinner. V3 said up to now, there has been no response from V1 on how to go about to get a copy of R1's records. At 10:10 AM, V1 initially said this was the first time V3 made a request…

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 investigate a bruise with an unknown origin to 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 3. The findings include: On 12/9/24 at 9:40 AM, R1 was sitting in her wheelchair, a fading bruise, yellowish greenish in color, was noted on the left side of R1's forehead. V3 (R1's sister/guardian) said that on 11/29/24, she noticed the bruise on the left side of R1's forehead. V3 said she wheeled R1 to where V1 (Administrator) and V4 (Registered Nurse/RN) were by the nurses' station and showed V1 and V4 the bruise and asked them what happened to R1. V3 said she worries when R1 develops any bruise because R1 is on blood thinners. V3 said she was not made aware of the bruise and wanted to see R1's medical record regarding the bruise. V3 said in October (2024), R1 had a bruise due to a fall but that was the right side of R1's forehead, this time it was on the left side of R1's forehead and she wanted to know how this bruise happened. R1's progress notes in November 2024 were reviewed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document the residents reason for discharge and failed to obtain physician documentation before discharging a resident for 2 of 3 (R10, R9) residents reviewed for discharge in the sample of 10. The findings include: 1. The facility's (Not part of medical record) Physical Aggression Initiated Report on R10 dated 11/20/24 shows writer observed resident agitated and yelling in hallway to staff members, writer and staff members asked if resident was alright writer ask resident if he needed assistance with anything trying to calm resident down with tone. writer observed resident grab object and throw towards staff while stating I missed on purpose resident is observed to have verbal aggression towards staff members while throwing objects directly onto staff member stating I'm going to kill them writer observed resident reach back with a closed fist and hit staff in eye resident continued yelling and pacing all resident near by was removed to safety writer…

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 notify a resident's guardian and the Ombudsman of a resident's involuntary discharge for 1 of 3 residents (R10) reviewed for discharge in the sample of 10. The findings include: The facility's (Not part of medical record) Physical Aggression Initiated Report on R10 dated 11/20/24 shows writer observed resident agitated and yelling in hallway to staff members, writer and staff members asked if resident was alright writer ask resident if he needed assistance with anything trying to calm resident down with tone. writer observed resident grab object and throw towards staff while stating I missed on purpose resident is observed to have verbal aggression towards staff members while throwing objects directly onto staff member stating I'm going to kill them writer observed resident reach back with a closed fist and hit staff in eye resident continued yelling and pacing all resident near by was removed to safety writer phoned 911 resident was sent out. On 11/25/24 at 10:31 AM, V1 (Administrator) said on 11/20/24, R10 was having…

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 allow a resident to return to the facility after a hospital stay and failed to document the reason for the refusal for 1 of 3 residents (R10) reviewed for discharge in the sample of 10. The findings include: The facility's (Not part of medical record) Physical Aggression Initiated Report on R10 dated 11/20/24 shows writer observed resident agitated and yelling in hallway to staff members, writer and staff members asked if resident was alright writer ask resident if he needed assistance with anything trying to calm resident down with tone. writer observed resident grab object and throw towards staff while stating I missed on purpose resident is observed to have verbal aggression towards staff members while throwing objects directly onto staff member stating I'm going to kill them writer observed resident reach back with a closed fist and hit staff in eye resident continued yelling and pacing all resident near by was removed to safety writer phoned 911…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement discharge planning for 1 of 3 residents (R9) reviewed for discharge in the sample of 10. The findings include: On 11/25/24 at 1:12 PM, V1 (Administrator) said R9 was transferred to another facility. V1 said V14 (Ombudsman) talked to R9 and came out to us and said the resident wanted to transfer to another facility. V1 said she spoke with R9 and he said he had family close by that facility. On 11/25/24 at 1:52 PM, V14 (Ombudsman) said she was at the facility and talked to R9. V14 said R9 said he wanted to transfer to a facility closer to his family. V14 said she told the facility staff but there was no discharge planner at the facility that day. V14 said V18 (Agency Registered Nurse) was working and she didn't know anything about discharging a resident. On 11/25/24 at 2:02 PM, V18 (Agency Registered Nurse) said on 11/8/24 she had been at lunch and when she returned, R9 was headed out the door transferring to another facility. V18 said V14 had…

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 a resident's discharge summary was complete for 1 of 3 residents (R9) reviewed for discharge in the sample of 10. The findings include: On 11/25/24 at 1:12 PM, V1 Administrator said R9 was transferred to another facility. V1 said the Ombudsman talked to R9 and came out to us and said the resident wanted to transfer to another facility. V1 said she spoke with R9 and he said he had family close by that facility. On 11/25/24 at 1:52 PM, V14 (Ombudsman) said she was at the facility and talked to R9. V14 said R9 said he wanted to transfer to a facility closer to his family. V14 said she told the facility staff but there was no discharge planner at the facility that day. V14 said V18 (Agency Registered Nurse) was working and she didn't know anything about discharging a resident. On 11/25/24 at 2:02 PM, V18 (Agency Registered Nurse) said on 11/8/24 she had been at lunch and when she returned, R9 was headed out the door transferring to another facility. V18 said V14 had talked to R9 and said he wanted to go to another…

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 incontinence care for a resident (R1) with a recent urinary tract infection. This applies to 1 of 3 residents reviewed for infections in the sample of 3. The findings include: R1's electronic face sheet printed on 11/18/24 showed R1 has diagnoses including but not limited to paranoid schizophrenia, dementia with behaviors, hypertension, chronic cystitis, dysphagia, and urinary tract infection. R1's care plan dated 11/7/24 showed, (R1) has bladder incontinence related to impaired mobility, weakness, and poor cognition .check around every 2 hours and as required for incontinence. Wash, rinse, and dry perineum . R1's hospital record/laboratory records dated 11/8/24 showed, R1 was diagnosed with a urinary tract infection. On 11/18/24 at 9:31AM, R1 stated, I have to go to the bathroom. V3 (Certified Nursing Assistant-CNA) stated, We can't take residents who use a mechanical lift to the toilet, they just go to the bathroom in their pants. I last changed (R1's) incontinence brief at 6AM when I came in today.…

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 a resident with severe cognitive impairment, poor safety awareness and a history of elopement was supervised in the facility courtyard after the door alarm did not sound and R4 exited the building. This applies to 1 of 3 residents (R4) reviewed for safety and supervision in the sample of 10. The findings include: R4's Face Sheet dated 10/2/24 shows that R4 has diagnoses including Disorders of the Brain, Adjustment Disorder with Anxiety, Mild Neurocognitive Disorder Due to Known Physiological Condition without Behavioral Disturbance, Epilepsy, Restlessness and Agitation and Dementia. R4's Progress Notes dated 3/3/24 state, Resident left through south C hall exit. CNA (Certified Nursing Assistant) and RN (Registered Nurse) attempted to bring resident back into facility, but resident refused and became aggressive with staff. RN called 911 as RN followed patient two blocks from facility. Police officers called ambulance who then escorted…

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 that residents' medications were delivered by individuals who have the skills, knowledge and proper licensure for 8 of 14 residents (R1-R6, R13 and R14) reviewed for medication administration in the sample of 14. The findings include: 1. R1's admission Record, provided by the facility on 9/26/24, showed he had diagnoses including, but not limited to, chronic embolism and thrombosis of deep veins of left lower extremity (chronic blood clots), bipolar disorder, depression, hypertension, cerebral infarction (stroke), chronic pain syndrome, anxiety disorder, and suicidal ideation. R1's facility assessment dated [DATE] showed he was cognitively intact. R1's care plan initiated on 12/7/23 showed he had allergies to certain medications. R1's Order Summary Report, printed by the facility on 9/26/24, showed orders for pain medications, anticoagulant medications, depression medications, anxiety medications, and antipsychotic medications. R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to timely reorder a controlled substance pain medication that the pharmacy required a new prescription from the physician. This failure resulted in a delay in obtaining a prescription from the physician and the resident missing up to 12 doses of this medication. This applies to one of three residents (R1) in the sample of three reviewed for pain medications. The findings include: The facility face sheet shows R1 was admitted to the facility for diagnoses to include spinal stenosis, bipolar disorder, and depression. The facility assessment dated [DATE] shows R1 to be cognitively intact. The Physician Order Sheet for September 2024 for R1 shows an order for Norco oral tablet one tablet by mouth four times a day for back pain. On 9/12/24 at 11:30 AM, R1 said on the Friday before Labor Day he asked the nurse if he had enough Norco to get through the holiday weekend and was told he did. R1 said then on Sunday the nurse told him he had run out of Norco. R1 said…

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

Based on interview and record review the facility failed to have interventions in place to mitigate the growth and spread of legionella and failed to maintain logs of interventions. This has the potential to affect all residents in the facility. The findings include: The CMS 671 shows 52 residents resides in the facility. On 5/23/24 at 12:41 PM, V1 (Administrator) said V3 (Maintenance Director) oversees Legionella management. V1 said the facility has not done any Legionella testing. On 5/23/24 at 1:16 PM, V3 said he doesn't know what legionella is or how to prevent it. V3 said he was never trained in legionella mitigation and didn't know he oversaw it. V3 said he has no logs showing he is doing mitigation efforts, except for random weekly water temperatures. The facility's Legionella policy and procedure showed the facility will establish and maintain a Water Management Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of pathogens in the water system such as Legionella. The policy showed the Legionella…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were provided influenza and pneumococcal immunizations as required. This applies to 3 of 3 residents in the sample (R46, R51, R20) reviewed for immunization in the sample 16 and 2 residents outside of the sample (R21, R54). The findings include: On 5/23/24 at 12:41 PM, V1 (Administrator) said, the administrator before her did not do a good job of tracking immunization. V1 said, I've been trying to find pneumonia information to know what immunizations the residents had and what they can have. V1 said, no screening and eligibility has been done, and vaccines have not been administered. V1 said vaccine refusal forms are not available for review. On 5/23/24 at 1:37 PM, V2 (Director of Nursing) said, she oversees influenza and pneumonia vaccines and V1 oversees COVID vaccines. V2 said, R46, R51, R20, R21 and R54 could have had Prevnar 23 but it was not offered. V2 said she is unsure if those residents were offered and refused or just were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were provided COVID vaccinations as required. This applies to 3 of 3 residents in the sample (R46, R51, R20) reviewed for COVID immunization in the sample 16, and 2 residents outside of the sample (R21, R54). The findings include: On 5/23/24 at 12:41 PM, V1 (Administrator) said, the administrator before her did not do a good job of tracking any immunization, and since she started, I've been trying to find COVID information to know what immunizations the residents had and what they can have. V1 said, no screening and eligibility has been done, and COVID vaccines have not been administered and refusal forms not available for review. On 5/23/24 at 1:37 PM, V2 (Director of Nursing) said, she oversees influenza and pneumonia vaccines and V1 oversees COVID vaccines. R20's Face sheet shows she was admitted on [DATE]. Her electronic medical records show no past or present COVID vaccination records. All immunization records were requested but…

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 a resident corridor had a section of handrail in place. This applies to 6 of 6 residents (R35, R46, R33, R10, R1, R40) reviewed for handrails in the sample of 16 and 8 residents (R37, R2, R34, R9, R54, R48, R12, R24) outside of the sample. The findings include: The facility provided list on 5/23/24 showed R35, R46, R33, R10, R1, R40, R37, R2, R34, R9, R54, R48, R12, and R24 lived on B hall. On 5/21/24 at 12:21 PM there was a missing section of handrail between room [ROOM NUMBER] and 21. The wall showed a broken handrail bracket and an indentation on the wall where the second handrail bracket had been. On 5/22/24 at 3:33 PM, V3 (Maintenance Director) stated, while looking at the missing section of handrail, he was not aware of the missing handrail. V3 stated he began his employment at the facility in February 2024 and he believed the handrail had been missing prior to his start date. V3 stated handrails are important for resident…

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

Based on observation, interview, and record review the facility failed to provide a window covering or provide a window covering in good repair for 3 of 4 residents (R35, R40 & R46) reviewed for privacy in the sample of 16. The findings include: 1. On 5/21/24 at 9:23 AM, R35 and R40 were roommates, and they did not have a window blind. Their window looked outside onto the facility grounds. On 5/21/24 at 9:23 AM, R40 was unable to answer questions regarding her blinds. On 5/21/24 at 9:23 AM, R35 stated she could not recall how long the blinds had been missing from her window; however, she believed it had been since she arrived in her room. R35 stated, I would like a blind. We have no privacy. Staff can see there is no blind in the window. R35's Electronic Health Record showed she had been in her room since November 2023. On 5/22/24 at 2:06 PM, V3 Maintenance Director stated he was not aware of the missing blind and he did not have a work order to replace the blind. On 5/22/24 at 2:06, while V3 was assessing the missing window in R35 and R40's room, a resident was outside 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 ensure a resident was free from abuse for 1 of 2 residents (R45) reviewed for abuse in the sample of 16. The findings include: The facility incident report form documents the alleged event occurred on 5/15/24 and was between R45 and R54. The same document shows both residents to be cognitively intact. R45 had medical diagnosis of bipolar, depression, anxiety disorder and suicidal ideations. R54 had diagnoses of schizoaffective disorder, and generalized anxiety disorder. R45's nursing progress note of 5/15/24 documents he had an altercation with another resident at approximately 6:30 PM. Residents were separated and redirected. R45 was assessed for injuries, lip laceration and bleeding noted on right lower lip. Resident said he was okay. On 5/21/24 at 12:20 PM, R45 said R54 used to live across the hallway from his room. R45 said R54 came into his room asking for smokes, crack, and lighters. He told him No and asked him to leave his room. R45 said as R54 was leaving his room, he turned around and sucker punched…

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 wound care as ordered by the wound care physician, failed to identify a wound on a resident's foot, and failed to document details regarding a resident's death. This applies to 2 of 3 residents (R46, R10) reviewed for non-pressure wound care in the sample of 16 and 1 resident (R56) outside of the sample reviewed for death. The findings include: 1. R10's admission Record (Face Sheet) showed an original admission date of [DATE] with diagnoses to include diabetes type 2, schizophrenia, and dementia. On [DATE] at 10:51 AM, R10 was in bed and on top of his right foot was an open wound with no dressing. The wound was the size of a pea, and the wound bed was dark purple. A 1 inch by 1 inch area surrounding the open wound was also dark purple. When asked about the wound, R10 waved his hands in a motion indicating the wound was no concern, he then grabbed a bottle of roll on deodorant and applied deodorant to the top of the wound. R10's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's respiratory care equipment was stored and administered in a manner to prevent cross contamination for 1 of 2 residents (R1) reviewed for respiratory care in the sample of 16. The findings include: R1's face sheet showed a [AGE] year-old male with diagnosis of respiratory failure, influenza A infection (3/27/24), chronic obstructive pulmonary disease, shortness of breath, anxiety disorder, and schizoaffective disorder. On 05/21/24 at 10:33 AM, R1 was in bed. There was an oxygen concentrator on the floor next to the bed. The concentrator was running at 2 liters and the nasal cannula tubing attached to the machine was on the floor. R1's oxygen tubing was dated 5/8/24. There was a nebulizer mask on top of R1's bedside table. It was not covered and was in direct contact with the furniture. The nebulizer tubing was dated 5/10/24. R3 (R1's roommate) put his call light on to notify staff R1 didn't have his oxygen on. V7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to date a vial of insulin when it was opened for 1 of 1 resident (R14) reviewed for insulin. The findings include: R14's admission record documents he was admitted to the facility on [DATE] with multiple diagnoses including Type 2 Diabetes Mellitus with hyperglycemia (high blood sugar). R14's May 2024 order summary report shows an order for insulin aspart 100 units/ml per sliding scale. On 5/22/24 at 1:10 PM, the A wing cart was observed to have a vial of insulin for R14, and the vial had no date noted when it was opened. The discontinue date was listed as 6/13/24. On 5/22/24 at 1:15 PM, V6 (Registered Nurse) said when a vial of insulin is opened it should be dated and discarded after 28 days. She said the vial for R14 only has the discard date, and the nurse should have noted the date it was opened. She said she could only assume it was 28 days prior to the 6/13/24 date listed, no way to know for sure. On 5/23/24 at 8:36 AM, V2 (Director of…

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

Based on observation, interview, and record review the facility failed to serve all menu items to a resident on a puree diet. This applies to 1 of 1 resident (R22) reviewed for puree diet in the sample of 16. The findings include: On 05/21/24 at 11:20 AM, V5 (Cook) prepared pureed Salisbury steak and carrots as V4 (Dietary Manager) supervised. No bread serving was pureed. On 5/21/24 at 12:15 PM, R22 was observed being fed his pureed lunch meal. No pureed bread or substitute was offered or available to him. Residents on diets other than puree were served bread. On 05/22/24 at 08:58 AM, V4 said R1 was the only resident on a pureed diet. V4 said she talked with the dietician yesterday and was told she should have served R1 bread yesterday. I was mixed up. On 05/23/24 at 10:27 AM, V4 said bread should have been served to R1 on 5/21/24 because it was on the menu and everyone else got it. If a menu item is not served, you need to substitute it with a comparable food item. V18 (Dietician) was unavailable for interview. V18 was called twice with no return call. The 5/21/24 facility menu…

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 and sanitize food preparation equipment in between food items for 1 of 1 resident (R22) reviewed for puree diet in the sample of 16. The findings include: On 05/21/24 at 11:20 AM, V5 (Cook) placed a serving of prepared Salisbury steak in the food processor. After pureeing the meat and plating, V4 (Dietary Manager) took the food canister and rinsed it under the faucet and returned it to the processor stand. V5 added a serving of carrots to the food processor, processed it and plated the food. The food processing canister was not washed or sanitized between the meat and vegetable food items. At 12:15 PM, R22 was observed being fed his pureed Salisbury steak and carrots. On 05/22/24 at 08:58 AM, V4 said R1 was the only resident on a pureed diet. V4 said she talked with the dietician yesterday and was told the food processing container should have been sanitized after each item was pureed. I was mixed up. On 05/23/24 at 10:27 AM, V4 said it's important to wash and sanitize the food processing container…

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 immediately report an injury of unknown origin to the Abuse Coordinator/Administrator for 1 of 3 residents (R1) reviewed for injuries of unknown origin in the sample of 4. The findings include: R1's face sheet shows she has diagnoses including Pick's Disease, Mental Disorder, Schizoaffective Disorder Bipolar Type, Mild Intellectual Disability, Anxiety Disorder, and Displaced Fracture of the Shaft of Right Clavicle. R1's active Care Plan shows the following: She has impaired cognition and altered mood and thought process with behavioral changes. R1 has a self-care deficit and requires staff assistance with her activities of daily living (ADL's) including toileting, transferring, and bathing. On 4/19/24 R1's care plan was updated to show R1 has a right mid clavicle fracture and requires her to wear a sling to her right arm and a wheelchair for mobility. On 4/30/24 at 7:55 AM, R1 was sitting in a wheelchair in the dining area of the facility. She had her right arm in a sling. R1 told this surveyor she fell into the bathtub 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 notify a resident's family/contact person regarding two falls and the resident being sent to a local hospital for evaluation for 1 of 3 residents (R5) reviewed for resident injury in the sample of 12. The findings include: R5's admission Record, provided by the facility on 4/4/24, showed she had diagnoses including schizophrenia, delusional disorder, anxiety disorder, major depressive disorder, restlessness, and agitation. R5's care plans, provided by the facility on 4/4/24, showed she has a history of falls and receives anticoagulant medication. On 4/2/24 at 8:05 AM, a local EMS (Emergency Medical Services) vehicle was parked by the front entrance of the facility. R5 was being taken out of the building on a gurney and placed into the EMS vehicle. V1 (Administrator) identified R5 as the resident being placed in the EMS vehicle and said that was the second fall she had this morning. At 10:50 AM, R5 returned to the facility via ambulance. R5 was seen twice on 4/2/24 sounding the exit alarms and having to be…

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

Based on observation, interview and record review, the facility failed to ensure a resident on anticoagulant therapy was sent out to a local hospital for evaluation after having a fall with a head injury for 1 of 3 residents (R5) reviewed for resident injury in the sample of 12. The findings include: On 4/2/24 at 8:05 AM, R5 was seen being taken out of the building on a gurney and placed in an EMS (Emergency Medical Services) ambulance vehicle. V1 (Administrator) identified the resident as R5 and said that R5 had two falls that morning. R5's progress notes showed her first fall on 4/2/24 was around 6:19 AM. The note showed R5 had a goose egg on the left back side of her head. R5's 4/2/24 progress notes showed R5 had an unwitnessed fall in the middle of her room at approximately 7:50 AM. Patient states that she doesn't know how it happened, but she is now on the floor and cannot move. The note showed R5 was assessed and due to the nature of the fall and R5 receiving anticoagulant therapy, R5 was sent to the ED (emergency department) for evaluation and treatment per doctor's orders.…

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 medications were stored in a locked medication cart or in a locked medication room for 2 (R4 & R8) of 11 residents reviewed in the sample of 12. The findings include: The facility data sheet, provided by the facility on 4/2/24, showed 54 residents resided in the facility. On 4/2/24 at 8:55 AM, four tubes and one container of prescribed topical creams were on R8's nightstand, in her and R4's room. The four tubes were nystatin cream (an antifungal cream used to treat a fungal or yeast infection), two tubes of triamcinolone acetonide cream (a topical cream used to manage and treat various conditions such as atopic dermatitis, contact dermatitis such as poison ivy, eczema, herpetiform psoriasis, subacute cutaneous lupus erythematosus, seasonal allergic rhinitis, among other conditions), a tube of hydrocortisone cream (a topical medication used to reduce the swelling, itching and redness in a variety of skin conditions). The tube 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 interview and record review the facility failed to ensure a resident's medical care was being overseen by a primary care physician. This applies to 1 of 3 residents (R1) reviewed for physician services in the sample of 3. The findings include: R1's face sheet shows he was admitted to the facility on [DATE] with diagnoses including chronic embolism and thrombosis of the left lower extremity, bipolar disorder, depression, and chronic pain syndrome. R1's 1/4/24 Minimum Data Set shows he is cognitively intact with no memory impairments. R1's care plan shows he has a history of inappropriate behaviors and will yell at staff/peers when he becomes agitated. On 2/28/24 at 8:17 AM, R1 said, The former Medical Director (V3) stopped seeing me in December and fired me from being his patient. Since then, I had no primary care physician, until yesterday, to prescribe my pain medication or oversee my care and monitor my Heparin that I take for blood clots. I told everyone I could I needed my pain medication ordered…

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 that a resident's medical record was complete with documentation from outside services the resident was receiving. This applies to 1 of 3 residents (R1) reviewed for medical records in the sample of 3. The findings include: On 2/8/24 at 9:30 AM R1 stated, I go to a therapist in town. Her name is (V11 Physical Therapist). My sister takes me, or she has a driver take me. I can walk with the walker but not without therapy. I can do it real good now. Make sure you tell my sister that I am doing real good. On 2/8/24 at 1:30 PM V2 (Director of Nursing) stated, I have no idea who she goes to for therapy. The CNAs do the restorative programs, and they document them under tasks. I really have nothing to do with restorative therapy. We have never heard from the physical therapist and never seen any of the paperwork. On 2/8/24 at 12:37 PM V6 (Registered Nurse/Minimum Data Set/Restorative) stated, She goes to a therapist in the community once or twice a week and I think we should be better about getting the notes…

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 who tested positive for Covid-19 were not allowed to work, and failed to ensure testing was completed for all staff and residents when a positive case was identified. This failure has the potential to affect all the residents in the facility. The findings include: The facility data sheet, provided by the facility on 1/10/24, showed 53 residents resided in the facility. On 1/10/24 at 11:48 AM, V11 (Certified Nursing Assistant/CNA) said the facility had an outbreak of Covid-19 about a month and a half prior. V11 said she came to work and found out that some of the residents had tested positive for Covid-19. V11 was asked if she was tested after the outbreak was identified, and V11 said she was not tested, she was just told to wear a mask. V11 said that V13 (the facility's previous Administrator) also had her come to work when she (V11) had tested positive for Covid-19. V11 said she tested positive on Monday, 12/18/23 and texted V13 to see what she should do. V11 showed this surveyor the text…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to monitor and assess a non-pressure wound for 1 of 2 residents (R1) reviewed for wounds in the sample of 11. The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including sepsis and pyoderma gangrenosum (auto-immune skin disorder). The facility quarterly assessment of 11/23/23 documents she cognitively intact. The 11/1/23 wound clinic reports document R1 was seen on 8/25/23 and 11/1/23. On 1/10/24 at 3:45 PM, V2 (Director of Nursing/DON) stated R1 does not see the in-house wound physician and goes to the outside clinic, and she has only been seen on these 2 dates and has no pending appointments. On 1/10/24 at 8:30 AM, V5 (Registered Nurse/RN) said R1 was transferred out to the local hospital yesterday because of her legs. She said R1's legs were probably infected. She has an auto-immune disorder that is almost like a flesh-eating disease. She has wounds from her knees down to her feet. V5…

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 utilize appropriate personal protective equipment (PPE) in COVID positive resident rooms, failed to utilize PPE during a facility-wide COVID-19 outbreak, failed to display isolation precaution signage outside resident rooms for residents currently on transmission-based precautions (TBP), and failed to monitor residents who are COVID-19 positive. These failures apply to 9 of 9 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9) reviewed for COVID-19 infection in the sample of 11 and has the potential to affect all residents. The findings include: On 11/16/23 at 8:58AM, Upon entrance to the facility there were no signs on the entrance to the facility indicating there were any COVID-19 positive residents or staff in the facility. On 11/16/23 at 8:59AM, the Surveyor entered the facility and immediately observed V10 (Certified Nursing Assistant/CNA) and V4 (Registered Nurse/RN) who were not wearing a mask or other face covering. On 11/16/23 at 9:13AM, V10 and V4 came to the nurse's station, each wearing an N95 mask. V4…

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 complete a dressing change as ordered by a Physician and failed to have off-loading interventions in place. The facility also failed to obtain an order for dressing changes on a resident upon admission, and failed to assess and document on a resident's wounds. This applies to 2 of 3 residents (R1 and R3) reviewed for pressure wounds in a sample of 9. The findings include: 1. R3's admission Record shows his diagnoses includes Type 2 diabetes mellitus with foot ulcer (left heel), major depression, anxiety, and mood disorder. On 11/7/23 at 9:15 AM, R3 was in bed. R3's heels were directly on his bed without heel boots on or have his heels elevated off the mattress. R3 had a regular mattress not a low air loss mattress. When R3 pulled the blanket off his feet he had grippy socks on, over the dressing on his left foot. A large amount of reddish drainage could be seen under his left heel on the bed sheet. R3's room had a foul odor. On 11/7/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to supervise a resident with a physician's order for 24/7 observation. This applies to one of four residents (R11) reviewed for safety/supervision in the sample of 11. The findings include: On 10/27/23 at 9:30 AM, R11 was observed leaving the building unattended by staff through the A wing exit door. The alarm for the door sounded and a nurse was observed going to the end of the hall to bring R1 back into the building. At 11:00 AM the same day, R11 was observed wandering the halls in the facility without any shoes or socks on, and no staff present with him. R11 was observed walking up and down the halls, standing at the exit doors, and entering other resident rooms. Later that same day, at 12:30 PM, R11 was observed wandering in the dining room after the other residents had finished eating. No staff were present. R11 was picking up leftover food from other residents' plates and eating it as he continued to wander unsupervised. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete a fall investigation and failed to put new interventions in place for fall prevention for a resident with a history of falls for 1 of 3 residents (R2) reviewed for safety and supervision. The findings include: R2's face sheet showed he was admitted to the facility 3/22/23 with diagnoses to include focal traumatic brain injury with loss of consciousness of 30 minutes or less, dysphagia, seizures, paralytic ileus, personality disorder, foot drop, essential hypertension, major depressive disorder, insomnia, and moderate intellectual disabilities. R2's facility assessment dated [DATE] showed he has mild cognitive impairment and requires extensive assistance from staff for most cares. R2's 7/19/23 nursing progress note showed, Resident was in the dining room and tried to grab something off of the floor. While leaning over resident fell over in his wheelchair. Resident's safety helmet was on. Resident complains of pain and was moaning after the fall…

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 a resident access to their personal funds. This applies to 4 of 7 residents (R1, R5, R6, R7) reviewed for personal funds in the sample of 7. The findings include: On 8/9/23 at 8:50 AM, R1 stated she is supposed to get $30 a month. R1 stated when R1asks the staff if R1 can have her money, they say no. On 8/9/23 at 10:34 AM, R5 stated at the end of May was the last time she was able to receive her money. The previous staff who was doing the banking got sick and no longer works at the facility. We're supposed to have banking days, but we have not had them since she left. R5's Trust Fund Transaction History from provided on 8/9/23 shows the last withdrawal was on 5/31/23. On 8/9/23 at 10:43 AM, R6 said he has not been able to get access to his money. On 8/9/23 at 10:47 AM, V3 (Social Services) said residents have been complaining about not having access to their personal funds. V3 referred this concern to V1 (Administrator). On 8/9/23 at 11:40 AM, V1 said the business office staff member left in June due to health…

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 serve all items listed on the menu. This applies to all 55 residents in the facility. The findings include: The Centers for Medicare and Medicaid Services (CMS) 672 dated 7/18/23 shows there are 55 residents in the facility. On 7/18/23 at 12:00 PM, the residents were served their lunch by V3 [NAME] and Dietary Manager. The menu for lunch showed Salisbury steak, mashed potatoes, brown gravy, carrots, bread and ice cream. The residents were not served the bread for this meal. On 7/18/23 at 12:40 PM, V3 said, I don't serve bread at lunch because they got toast with breakfast and are having a deli sandwich for supper, which would be 6 servings of bread in one day. On 7/19/23 at 2:00 PM, V1 Administrator said V3 promised her she would not change the menu anymore. She was told it's important to follow the menu so the residents get the food prescribed for them. The residents could lose weight if not served all the food listed on the menu. On 7/20/23 at 12:22 PM, V19 Dietician said the menus are to be followed 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 cool leftovers in a safe manner to prevent food bourne illness. This applies to all residents in the facility. The findings include: The Centers for Medicare and Medicaid Services (CMS) 672 dated 7/18/23 shows there are 55 residents in the facility. On 7/18/23 at 9:31 AM, leftovers observed in the refrigerator included chicken and rice dated 7/17/23, roast pork dated 7/12/23 and Chicken [NAME] dated 7/15/23. On 7/18/23 at 12:40 PM, V3 [NAME] and Dietary Manager said the facility does not do cooling logs. V3 said she just leaves the food on the counter to cool and then checks the temperature before placing it in the refrigerator. V3 said the temperature should be the same at the refrigerator temperature. On 7/19/23 at 2:00 PM, V1 Administrator said proper cooling is important to prevent bacteria from entering into the food and getting the residents sick. On 7/20/23 at 12:22 PM, V19 Dietician said cooling needs to be completed for all leftovers and meats cooked ahead of time to prevent bacteria from developing…

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 effectively manage flies throughout the facility. This applies to all 55 residents residing in the facility. The findings include: On 7/18/23 at 9:39 AM, R10 was self-propelling his wheelchair about his room. There were several flies buzzing around the room. Throughout the interview, flies landed on R10's face and arms. R7 (R10's roommate) had a open urinal with dark yellow urine inside it. The urinal did not have a lid on it and was hooked to the garbage can. The flies landed on the inside of R7's used urinal, flew around the room, and landed on R10's arms and face. R10 swatted at the flies repeatedly, eventually loudly signing and say, UGH! I need a flyswatter! These flies are so annoying! R7 was on his bed and the flies continually landed on his face and arms. R7 was grunting and swatting at the flies. On 7/18/23 at 9:52 AM, R35 was self-propelling his wheelchair from his room toward the nurses' station. R35 stopped in the hall to speak with the surveyor. R35 had urinary catheter tubing coming from 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 sanitize the blood glucose meter between the residents to prevent the spread of infections. This applies to 9 residents (R9, R12, R15, R20, R23, R28, R29, R50, R108) in the sample of 15 and 5 residents (R16, R18, R24, R25, R26) outside the sample reviewed for infection control. The findings include: On 7/18/23 at 11:00 AM, V4 Registered Nurse (RN) was observed checking a blood glucose level on R50. When V4 was finished she took an alcohol wipe and wiped the glucometer off. V4 said the facility is currently out of the bleach wipes she usually uses to clean the glucometer with. V4 said she was not aware if more had been ordered. On 7/20/23 at 10:15 AM, V5 RN said she cleans the blood glucose meter with alcohol wipes after each resident use. V5 said she was not aware of what the bleach wipes were. On 7/20/23 at 11:30 AM, V1 Administrator said the blood glucose meter must be cleaned with bleach wipes to properly sanitize it between the residents to prevent the spread of infections. The facility provided a list of…

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

Based on observation, interview, and record review the facility failed to ensure a resident shower room was maintained in a safe condition. This failure affects 11 residents (R25, R12, R35, R27, R4, R30, R11, R3, R28, R6, R20) that use the specific shower room. The findings include: On 7/18/23 at 9:36 AM, the shower R25's hall was inspected. The shower was recently cleaned and R27 was self-propelling his wheelchair toward the shower room. The shower room has partial walls that separate the toilet and dressing area from the shower. The shower floor consisted on 1 inch, square tiles. There were 3 large areas of tile missing from the shower floor, making the floor uneven and a potential safety hazard. There was an irregular shaped area of tiles missing around the drain. There was a irregular shaped area of missing tiles that was 4 tiles by 4 tiles, this entire area had a a gray/black, fuzzy appearance on the exposed ground. There was another irregular shaped area that was 2 tiles x 4 tiles with an additional row of 2 tiles missing. There were over 20, 1-inch square tiles missing from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident advanced directives were consistent throughout the medical chart for 1 of 3 residents (R20) reviewed for advanced directives in the sample of 15. The findings include: R20's Face Sheet dated [DATE] showed diagnoses to include, but no limited to: schizoaffective disorder, irritable bowel syndrome, depression, mood disorder, anxiety, hypertension, emphysema, vascular dementia, and aphasia. R20's Physician Order Sheet dated [DATE] showed an order for R20 to be a Full Code. This order was entered on [DATE]. R20's IDPH POLST (Practitioner Order for Life-Sustaining Treatment) Form signed by the physician on [DATE] showed R20 elected Do Not Attempt Resuscitation/DNR. On [DATE] at 3:17 PM, V4 (RN - Registered Nurse) said the facility no longer documents paper charts. They switched to the EMR (Electronic Medical Record). V4 said the facility just transitioned in [DATE] and the hard charts are still locked in V8's office (MDS Coordinator/RN). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to report an allegation of theft to the state agency for 1 of 1 residents (R29) reviewed for abuse in the sample of 15. Findings include: On 7/18/23 at 12:09 PM, R29 was self-propelling her wheelchair in her room. R29 said she has been at the facility for 3 months and people keep stealing her stuff. R29's room has numerous belongings, taking up most of the double room. There were not any of R29's personal belongings stored on the empty bed in the room. R29 had large, plastic totes with pad locks on them. R29 was wearing a chain around her neck with several keys on it. R29 stated, My debit cards were stolen and charges were made by someone else. First I told [V1, Administrator], then [V8, MDS Coordinator], then [V7, Social Services Director], but they acted like they didn't give a (expletive). There was no investigation. Everyone should have been interviewed. I reported it to [the debit card company]. There were charges from (a cash…

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 an allegation of theft was thoroughly investigation for 1 of 1 residents (R29) reviewed for abuse in the sample of 15. The findings include: On 7/18/23 at 12:09 PM, R29 was self-propelling her wheelchair in her room. R29 said she has been at the facility for 3 months and people keep stealing her stuff. R29's room has numerous belongings, taking up most of the double room. There were not any of R29's personal belongings stored on the empty bed in the room. R29 had large, plastic totes with pad locks on them. R29 was wearing a chain around her neck with several keys on it. R29 stated, My debit cards were stolen and charges were made by someone else. First I told [V1, Administrator], then [V8, MDS Coordinator], then [V7, Social Services Director], but they acted like they didn't give a (expletive). There was no investigation. Everyone should have been interviewed. I reported it to [the debit card company]. There were charges from 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 was safe when a sling for a mechanical lift was applied and when the resident was up her motorized wheelchair for 1 of 5 residents (R108) reviewed for safety and supervision in the sample of 15. The findings include: On 7/18/23 at 11:14 AM R108 was sitting in her extra large/bariatric motorized wheelchair outside on the patio where residents smoke. R108 is morbidly obese and was trying to get her motorized wheelchair through the door to get back into the facility. R108 got stuck in the doorway and the wheels of her wheelchair were spinning on a mat at the doorway. The rug was getting bunched up and caught behind the front wheels of her wheelchair. R108 kept spinning her wheels; she couldn't move forward or backward. R108 was yelling for a Nurse Aide (NA) to help her. V12 CNA (Certified Nursing Assistant) was outside with the other residents that were behind R108 on the patio. V11 CNA came to the doorway, saw what was going on, and went to get the nurse. V11 CNA came back with V20 RN…

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 pain management was provided for a resident in pain from his hemorrhoids for 1 of 2 residents (R105) reviewed for pain in the sample of 15. The findings include: On 7/18/23 at 9:32 AM, V11 CNA (Certified Nursing Assistant) was in R105's room providing incontinence care for the resident. V11 was cleaning feces off of R105's anus and buttocks. R105 complained of pain; he stated his butt hurt. V11 stated she would put the barrier cream on his buttocks and anus and let the nurse know about his hemorrhoid. V11 put a new incontinence brief on the resident, pulled up his blankets and left the room. The nurse never came down to his room. R105 stated he has had the hemorrhoid for couple weeks. R105 stated his butt hurts and the pain keeps him awake at night. R105 stated the nurses should know about it because he has been telling them about it. The Physician Orders for R105 showed on 7/13/23 Anusol HC cream was ordered to be applied to the affected area topically as needed for hemorrhoids, twice a day as needed.…

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.