Forest City Rehab & Nrsg Ctr

Based on observation, interview and record review the facility failed to provide incontinence care to and reposition a resident dependent on staff for these cares for 1 of 33 residents (R27) reviewed for activities of daily living (ADLs) in the sample of 33.The findings include:R27's current care plan showed R27 was nonverbal and cognitively impaired due to his diagnoses of intellectual disability and paralytic syndrome. The plan showed R27 is dependent on staff for toileting/incontinence care, transfers and repositioning. R27 was incontinent of bowel and bladder. The plan showed staff will reposition R27 as per facility protocol and keep R27's skin clean and dry. On 11/17/25 at 10:21 AM, R27 was seated in a high-back wheelchair in his room. R97 (R27's roommate) was also in the room. R97 looked at this surveyor and stated, He (R27) doesn't talk. When R97 was asked how long R27 had been up in his wheelchair that morning, R97 stated, He's been up in the wheelchair since around 5 AM. They (staff) don't lay him down much during the day. On 11/17/25 at 11:36 AM, R27 remained seated in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure electrical wiring was appropriately insulated and stowed out of reach in one resident's room (R149) and failed to ensure a resident was transferred in a safe manner for 2 of 6 residents (R149, R147) reviewed for safety in the sample of 33. The findings include: 1. On 11/18/25 at 12:53PM, R149 showed the surveyor two wires sticking out of the wall in the resident's room. R149's room has a black and a white electrical wire hanging out of a conduit tube under the window. The electrical wires were wrapped with black electrical tape. On 11/18/25 at 1:25PM, V12 Maintenance used a voltage tester to check the electrical wires. The voltage tester started flashing and emitted a tone signifying electrical current was present in the wires. V12 Maintenance said, there is 120 volts of electrical power coming through the wires. The wires should be enclosed with wire caps (rather than electrical tape). The facility's Preventative Maintenance…

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 a residents urinary catheter bag below the level of the bladder and off the floor for 2 of 7 residents (R82, R3) reviewed for urinary catheters in the sample of 33.The findings include:1.R82's current care plan showed R82 had a urinary catheter in place due to his diagnoses of prostate cancer and obstructive and reflux uropathy. The plan showed R82 is at risk for infection or complications related to catheter use.Observe position of drainage bag and keep below waist to ensure proper drainage. R82's progress note dated 11/5/25 showed R82 developed blood in his urine. R82's physician/nurse practitioner was notified. A urinalysis of R82's urine was ordered. R82's urinalysis result dated 11/11/25 showed R82 was diagnosed with a urinary tract infection (UTI) and started on antibiotics for treatment of the UTI. On 11/17/25 at 8:53 AM, R82 was in bed, lying on his right side. The catheter bag, connected to R82's urinary catheter, rested…

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 consistently document meal intakes and monthly weights and failed to ensure a resident (R40) was assessed by the dietician following a significant weight loss. This failure resulted in additional interventions not being implemented and R40 experiencing on going weight loss. The facility failed to ensure nutritional interventions were implemented for 4 residents (R9, R14, R153, R160) and failed to ensure weekly weights were obtained for a resident (R153). The findings include:1. On 11/19/2025 at 10:26AM, V14 Dietary Manager said, I perform admission and quarterly nutritional assessment on the residents. The dietitian uses my assessments and performs their own assessment. The dietitian only assesses residents if the computerized medical record triggers the resident for weight loss. The problem with R40's weight loss is the computer did not trigger the weight loss because no weights were documented. I was not made aware R40's weights were not being documented. From January 2025 through July 2025 R40's Medication Administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to administer medications as ordered by the physician. There were 28 opportunities with 2 errors resulting in a 7.14% error rate. This applies to 2 of 4 residents (R17, R70) observed in the medication pass. The findings include:1.R17's Order Summary Report shows he was admitted to the facility on [DATE], with a diagnosis of type two diabetes mellitus with diabetic neuropathic arthropathy. R17 has an order for humalog tempo pen inject 15 units subcutaneously three times a day for diabetes.On November 17, 2025, at 11:00 AM, V19 Licensed Practical Nurse (LPN) prepared R17's insulin pen by placing a needle on the end. V19 turned the dial on R17's pen to 15 units. V19 then administered the insulin to R17's abdomen. V19 did not prime the insulin pen and needle by wasting two units of insulin prior to administering the insulin to R17. V19 said she only primes the insulin pen when she opens a new pen, not with each administration.On November 18, 2025,…

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 R125 a snack outside of the scheduled meal service times for 1 of 5 residents (R125) reviewed nutrition in the sample of 33.The Findings Include:On 11/18/25 at 9:08AM, R125 said, I do not get snacks. I would like a bedtime snack. When I request a bedtime snack, V14 Dietary Manager tells me, only the diabetics get snacks. On 11/18/25 at 9:35AM, V13 LPN-Licensed Practical Nurse said, the facility only provides diabetic residents and residents with weight loss a snack at night.On 11/18/25 at 10:20AM, V14 Dietary Manager, we do not offer snacks to anyone. Diabetic residents are the only residents the snacks are set up for in the evening.On 11/18/25 at 1:38PM, V15 Dietitian said, we only provide snacks to diabetics.R125's Diet Order dated 10/02/2017 shows, regular texture, thin liquids, consistency for general diet.On 11/18/25 R125's Care Plan show, no intervention forbidding R125 from having a snack outside of scheduled meal service times.On 11/18/25 R125's Physician's Orders show, no Physician Order forbidding R125…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff wear personal protective equipment (PPE) and have signs posted for residents on enhanced barrier precautions (EBP) isolation which applies to 2 of 33 residents (R117, R82) reviewed for infection control in a sample of 33.The findings include: 1) R117's Medical Record showed R117's is a [AGE] year-old female resident readmitted to the facility on [DATE] with diagnoses which includes Stage 4 pressure ulcer of the sacral (tailbone) region. On 11/17/25 at 12:30 PM V5 and V6 Certified Nursing Assistants (CNAs) entered R117's room, performed a mechanical lift transfer, and peri-care without placing a blue gown on prior to entering the room. R117 has a sign on the door for EBP isolation precautions to be used. R1's Physician Orders printed on 11/17/25 showed R117 has dressing change orders which include using a crushed antibiotic and antibacterial solution to be applied to R117's wound. On 11/18/25 at 2:45 PM V4 Infection Control…

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 pressure injury treatments were being completed for 2 of 3 residents (R2 & R3) reviewed for pressure injury in the sample of 4.The findings include:The findings include:1. Face Sheet dated 10/21/25 for R2 showed diagnoses including stage 4 pressure ulcer to the left lower back, type 2 diabetes mellitus, chronic obstructive pulmonary disease, adult failure to thrive, gastroesophageal reflux disease, anxiety, falls, and peripheral vascular disease.The Wound Care Physician Note dated 10/16/25 for R2 showed a stage 4 pressure wound to the left lower back with the objective of treatment to prevent deterioration. The October 2025 Treatment Administration Record (TAR) for R2 showed, collagen matrix silver external sheet - apply to wound topically one time a day every Saturday and Sunday for wound care and it was not signed off as being completed on 10/4/25 and 10/5/25. Wound care: left lower back - cleanse with wound cleanser, skin prep to peri wound, pack with collagen with silver and cover with gauze island…

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

Based on interview and record review the facility failed to follow their abuse policy by not immediately reporting, investigating and protect residents while and investigation is underway for 1 of 3 residents (R1) reviewed for abuse in the sample of 9. The findings include: The facility's Abuse Prevention Program Facility Policy and Procedure dated 10/2023 shows, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator .Upon learning of the report, the administrator or a designee shall initiate an incident investigation .The facility will take steps to prevent potential abuse while the investigation is underway Employees of the facility who have been accused of abuse will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator .The investigator will…

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 allegation on abuse to the state survey agency for 1 of 3 residents (R1) reviewed for abuse reporting in the sample of 9. The findings include: R1's Care Plan shows, [R1] is at risk for abuse and/or neglect due to her mental illness and hx (history) of abuse .Follow facility policy for all suspected or reported instances of abuse and/or neglect. Take all reports seriously . R1's Hospital After Visit Summary dated 6/15/25 shows, Patient does not like this facility and she keeps trying to elope. She stated that staff started to restrain and fight with her so she fought back .Adult Protective Services being notified . R1's Nursing Notes dated 6/15/25 at 11:47 PM shows, Resident returned via stretcher accompanied per [Ambulance Company] Attendants(2) while taking resident to bedroom,resident replied,Look my favorite person,the one that assaulted me. [Attendant's Name] intervened/re-directed.false belief On 6/17/25 at 10:50 AM, V11, Certified Nursing Assistant (CNA) said that R1 returned from the hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately investigate an allegation of abuse and failed to immediately suspend the alleged perpetrator while the investigation was in process for 1 of 3 residents (R1) reviewed for abuse in the sample of 9. The findings include: R1's Hospital After Visit Summary dated 6/15/25 shows, Patient does not like this facility and she keeps trying to elope. She stated that staff started to restrain and fight with her so she fought back .Adult Protective Services being notified . R1's Nursing Notes dated 6/15/25 at 11:47 PM shows, Resident returned via stretcher accompanied per [Ambulance Company] Attendants(2) while taking resident to bedroom,resident replied,Look my favorite person,the one that assaulted me. [Attendant's Name] intervened/re-directed.false belief On 6/17/25 at 10:50 AM, V11, Certified Nursing Assistant (CNA) said that R1 returned from the hospital around 11:30 PM on 6/15/25. V11 said that upon her return, R1 looked at her and said, That is my…

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

Based on interview and record review the facility failed to report an allegation of alleged sexual abuse within the required timeframe to the Illinois Department of Public Health (IDPH). This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 10. The findings include: R1's progress notes dated June 1, 2025 shows, R1 was discharged home on May 31, 2025 after being out on pass with her daughter (V11). V11 R1's Daughter decided to keep her home and not bring her back to the facility. On June 5, 2025 at 9:55 AM, V11 R1's daughter stated, after she removed her mom from the facility R1 told her that someone raped her while she was the facility. She reported that to V3 Admissions. On June 5, 2025 at 10:45 AM, V3 Admissions stated, V11 R1's daughter called her on Monday or Tuesday (June 2nd/June 3rd) to report a missing cell phone. During the phone call V11 stated, R1 told her that someone sexually abused her while she was the facility. She reported that information to V1 Administrator. On June 5, 2025 at 1:00 PM, V1 Administrator stated, V3 Admissions did report to him…

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 food was served at a temperature to meet resident satisfaction for 4 of 4 residents (R1, R2, R3, and R13) reviewed for food temperatures in the sample of 13. The findings include: R1's face sheet showed he was admitted to the facility on [DATE]. R1's facility assessment dated [DATE] showed he has no cognitive impairment. On 2/18/25 at 12:10 PM, R1 said the food is always cold. R1 said he was told by V8 (Dietary Manger) that the temperature meets state requirements but that by the time it is served its cold. R2's face sheet showed he was admitted to the facility on [DATE]. R2's facility assessment showed he has no cognitive impairment. On 2/18/25 at 12:27 PM, R2 said, The food is not hot most of the time. I have to go heat it up in the microwave a lot. R3's face sheet showed he was admitted to the facility on [DATE]. R3's facility assessment dated [DATE] showed he has no cognitive impairment. On 2/18/25 at 12:30 PM, R3 said the food…

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 food was held at required temperatures on the second floor steam table and failed to ensure food was served in a manner to prevent cross contamination. This applies to all 94 residents residing on the second floor. The findings include: The facility provided a resident roster on 2/18/25 showing 94 residents residing on the second floor. 1. On 2/18/25 at 11:46 AM, there was regular texture shredded chicken, regular texture rice, regular texture corn, creamed corn, and two divided plates that had already been served with pureed chicken, pureed rice, and pureed corn on the second floor steam table. The regular texture chicken was 117 degrees, the regular rice was 129 degrees, the mechanical soft chicken was 125 degrees, the pureed chicken was 106 degrees, the pureed rice was 118 degrees, and the pureed corn was 104 degrees. R1's face sheet showed he was admitted to the facility on [DATE]. R1's facility assessment dated [DATE] showed he…

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 had his prescribed medication when leaving the facility on a pass home overnight for 1 of 3 residents reviewed for medications in the sample of 3. The findings include: The Nurse's Notes dated 11/28/24 for R1 did not show that he left the building on a pass with his power of attorney. A handwritten note given to R1's POA (Power of Attorney) on 11/28/24 showed, R1 does not have medication strip to provide his mother while out on pass. The note was signed by V4 LPN (Licensed Practical Nurse). The MAR (Medication Administration Record) dated November 2024 for R1 showed on 11/28/24 R1 received his morning medications. R1's evening medications for 11/28/24 were latanoprost opthalmic 0.005%, melatonin 3mg, benztropin mesylate 1mg, depakote 250 mg, depakote 500mg, lorazepam 0.5 mg, pepcid 20 mg, risperidone 0.25 mg. R1's morning medications for 11/29/24 were: aripirazole 5mg, atenolol 50 mg, furosemide 20 mg, spironolactone 50 mg, benztropine mesylat 1 mg, depakote 250 mg, depakote 500 mg, lorazepam…

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

Based on interview and record review the facility failed to report an allegation of abuse to the administrator of the facility for 1 of 3 residents (R1) reviewed for abuse in the sample of 9. The findings include: On 10/30/24 at 10:00AM, V1 Administrator said, I was not informed about an alleged incident between R1 and V3 CNA-Certified Nursing Assistant, I will investigate the allegation immediately. On 10/30/24 at 2:27PM, V5 Scheduler said, I received a report from R1's daughter that R1 received a ham sandwich. She reported that someone pushed her. I did not tell V1. On 10/30/24 at 1:00PM, V1 stated he reviewed the video footage regarding the alleged incident. V3 made no contact with R1. On 10/30/24 at 12:07PM, V3 CNA said, if an abuse like allegation was reported to me, I would contact V1 Administrator immediately, I would not worry about chain of command. I would report to my nurse also but V1 first. The facility's Abuse Prevention policy dated 11/18/2016 shows, employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation,…

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 enhanced barrier precautions were in place for a resident with a pressure injury. The facility failed to ensure soiled linen was not discarded on the floor and gloves were changed after care and before touching other contact surfaces to prevent cross contamination for 2 of 2 residents (R122 & R151) reviewed for infection control in the sample of 33. The findings include: 1. The Nurse's Notes dated 10/11/24 at 3:56 PM for R122 showed, resident admitted from the hospital via ambulance stage two on coccyx area at this time. The Nurse's Note dated 10/18/24 at 1:13 PM for R122 showed, R122 is alert, disoriented, but can follow simple instructions; has difficulty making needs known. R122 needs mechanical lift (2 person assist) for transfers, eating with total assistance, dressing/hygiene with total assist, and is incontinent of urine, is incontinent of bowel. Resident is non-verbal due to previous CVA (cerebral vascular accident), with hemiplegia, she is dependent on staff for all ADL's (activities of daily…

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

Based on observation, interview, and record review the facility failed to handle food in a manner to prevent cross-contamination. This failure has the potential to affects all residents residing on the first floor. The findings include: The facility resident census, provided on 10/22/24, showed 81 residents out of 164 residents, reside on the first floor. On 10/22/24 at 9:49 AM, V32 (Dietary Manager) stated the noon meal was open face turkey sandwich and alternatives included but not limited to hamburgers, grilled cheese sandwiches, and cold meat sandwiches. On 10/22/24 at 11:37 AM, V33 (Cook) began lunch service on the first floor. During the lunch service, V33 grabbed the hamburger patties from the container with her gloved hand after she had touched potentially contaminated surfaces such as handles, bags, food containers, and horizontal surfaces. V33's did not change gloves and her gloves developed a layer of grease on them. V33 would then grab a slice of bread for the open face turkey sandwich with the same greasy glove. V33's fingers also contacted the top of the plates leaving…

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 advanced directive was accurate for 1 of 1 resident (R153) reviewed for advanced directives in the sample of 33. The findings include: On 10/22/24 at 3:35 PM, R153's electronic medical record was reviewed and showed in the banner under his name that his advanced directive was DNR (Do Not Resuscitate). The Physician Orders for R153 showed on 4/17/24 and order for DNR; this was the only active code status order. The POLST (Practitioner Order For Life-Sustaining Treatment) form dated 9/13/24 for R153 showed he was a full code. The Face Sheet for R153 dated 10/23/24 showed, Advance Directive - Do Not Resuscitate. On 10/23/24 at 8:07 AM, V22 (LPN/Licensed Practical Nurse) stated she knows what a resident's code status is by looking at their wristband and MAR (Medication Administration Record). The wristband will tell you if the resident is a DNR. V22 stated in the resident's chart (electronic medical record) it says a residents code status at the top (by resident name). V22 stated she can also…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify a resident's representative of an involuntary transfer to the hospital for 1 of 3 residents (R167) reviewed for notifications in the sample of 33. The findings include: R167's Facesheet dated 10/22/24 showed diagnoses to include, but not limited to: stroke due to embolism, nicotine dependence, encephalopathy, hypertension, deep vein thrombosis, chronic obstructive pulmonary disease, unsteadiness on feet, repeated falls, weakness, and long-term use of anticoagulants and antithrombotics/antiplatelets. This document showed V27 was listed as Emergency Contact #1. R167's facility assessment dated [DATE] showed he had severe cognitive impairment. R167's Social Service Note dated 9/27/24 at 6:27 PM, showed R167 was admitted from the hospital at 2:30 PM. R167 was alert and disoriented with no psychiatric diagnosis at the time of admission. R167 is not oriented to place/time/situation. This note showed shortly after admission, R167 wanted to leave 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 ensure treatment orders were in place for a resident with a new drain site, failed to ensure the ordered dressings were in place for a resident with wounds, and failed to do initial wound assessments for a resident for 2 of 2 residents (R521, R45) reviewed for wounds in the sample of 33. The findings include: 1. R521's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include bipolar disorder, pleural effusion, anxiety disorder, insomnia, ileostomy, and major depressive disorder. R521's complete care plan was reviewed and showed no evidence of R521's accordion drain for her liver abscess. R521's care plan initiated 10/4/24 showed, . Change midline dressing every Friday . On 10/22/24 at 2:08 PM, R521 was lying in her bed. R521 showed this surveyor her liver drainage site to her right upper abdomen. There was an undated dressing over the site. R521 said the dressing was placed at the hospital and has not been…

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

Based on observation, interview, and record review the facility failed to ensure a resident had a catheter secure device in place for 1 of 3 residents (R49) reviewed for indwelling urinary catheters in the sample of 33. The findings include: On 10/24/24 at 9:34 AM, R49 was laying on his back in bed. V28 (CNA/Certified Nursing Assistant) and V29 (CNA) were giving R49 a bed bath. R49 did not have catheter secure device in place for his catheter tubing. R49's catheter tubing was pulled tightly to the left and his drainage bag was secured to the lower part of the bed frame. V28 and V29 stated they did not realize he did not have a catheter secure device in place. V28 stated she wasn't aware of R49's catheter coming out. R49 nodded yes that his catheter has come out and put up two fingers. R49 was asked if his catheter came out twice and he nodded yes to confirm. R49 is able to make hand gestures and nod yes/no for communication. R49 was asked if he would let the facility put a device on to hold his catheter tubing in place to try and prevent any trauma and he nodded yes. On 10/24/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store respiratory equipment in a manner to prevent contamination and failed to date respiratory equipment when changed for 2 of 2 residents (R144, R126) reviewed for oxygen in the sample of 33. The findings include: 1. R144's face sheet showed a [AGE] year-old male with diagnosis of chronic obstructive pulmonary disease, acute and chronic respiratory failure, anxiety disorder, and hypertension. On 10/22/24 at 11:02 AM, R144 was in his room in a wheelchair. R144 was alert and oriented X3 and had oxygen running at 2 liters per nasal cannula via a portable oxygen concentrator. There were no markings on the oxygen tubing to indicate when it was started. At 11:17 AM, there was an oxygen concentrator in the room turned on and running. There was oxygen tubing in contact with the floor and the end of the cannula was on the bed. There was a CPAP (continuous positive airway pressure) mask connected to a machine on the bedside table. The facemask 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 2. R153's admission Record (Face Sheet) showed he was type 2 diabetic. R153's Order Summary Report (dated 10/23/24) showed an active order for fast acting insulin to be given four times a day. The order showed the insulin dosage was based on blood sugar levels. The order showed 8 units of insulin should be given for a blood sugar reading between 301 and 350. On 10/23/24 at 10:54 AM, V6 (Licensed Practical Nurse/LPN) measured R153's blood sugar to be 338. V6 then attached a needle to R153's fast acting pre-filled insulin pen. V6 dialed in 8 units of insulin, entered R153's room, and wiped the back of his right arm with an alcohol wipe. V6 then pressed the needle into R153's arm, depressed the plunger button, and held the button for less than 3 seconds. V6 did not wipe the pen tip with alcohol prior to attaching the needle and she did not prime the insulin pen. On 10/23/24 at 12:57 PM, V2 (Director of Nursing) stated, V6 should have wiped the tip of the insulin pen prior with alcohol prior to attaching the needle…

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 date opened insulin pens. This applies to 2 of 2 residents (R153, R166) reviewed for medication storage in the sample of 33. The findings include: 1. On 10/24/24 at 10:45 AM, The 200-hall medication cart was reviewed with V9 (Licensed Practical Nurse/LPN). R153's fast-acting insulin pen had a yellow sticker with three areas for documentation. The areas were Date Open, Date Expire, and Initials; all three areas were blank. R153's insulin pen showed no handwritten dates elsewhere on the pen. The pen had a red tamper seal around the pen cap, which was damaged, indicating the pen had been opened. R153's fast-acting insulin pen also had coarse milliliter graduations which showed some insulin had been dispensed. V9 stated she had given R153 insulin from that pen earlier in her shift. V9 said whoever opens the pen is supposed to date the pen. R153's Order Summary Report (dated 10/23/24) showed an active order for fast-acting insulin to be given four times a day. On 10/24/24 at 11:16 AM, V2 (Director of Nursing/DON)…

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 safe feeding recommendations for 4 of 10 residents (R2,R3,R6,R9) reviewed for safety and supervision in the sample of 10. The findings include: 1) R2's electronic face sheet printed on 7/1/24 showed R2 has diagnoses including but not limited to dysphagia (oropharyngeal phase), bipolar disorder, dementia without behaviors, and schizophrenia. R2's facility assessment dated [DATE] showed R2 has mild cognitive impairment and receives a mechanically altered diet. R2's care plan dated 7/26/17 (Revision 6/11/24) showed, (R2) has a general, pureed texture, nectar thickened liquids diet . R2's speech therapy recommendations dated 6/5/24 showed, Mechanical soft, thin liquids, slow rate, small bites and sips, alternate solids & liquids, upright position. R2's local hospital records dated 4/29/24 showed, Patient is a resident of (facility) and was sent to the emergency department with concerns of acute encephalopathy/altered mental status.…

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's family/Power of Attorney were informed of their change in condition and hospitalization for 1 of 3 residents (R1) reviewed for change in condition in the sample of 3. The findings include: On 4/9/24 at 11:45 AM, V5, Licensed Practical Nurse (LPN), said if a resident goes to the hospital, the POA/family is notified. V5 said the nurse documents who was informed and when they were informed of the resident's change in condition/status in the resident's Nurse's Notes. On 4/9/24 at 12:07 PM, V9, LPN, said the nurse informs a resident's family/POA/Guardian when a resident goes to the hospital and documents when they are informed in Nurse's Notes. On 4/9/24 at 1:24 PM, V10, R1's family/POA, said she is R1's POA and she was not informed by the facility that R1 was unresponsive and being sent to the hospital (on 1/3/24). V10 said she got a phone call from someone at the hospital asking her if she knew her loved one (R1) was in the hospital. V10…

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 and interview the facility failed to ensure the shower room was kept clean and sanitary. This applies to all 168 residents residing in the facility. The findings include: The facility data sheet dated March 27, 2024 shows there are 168 residents residing in the facility. On March 27, 2024 at 9:15 AM, the first floor shower room on the 200 hall had a black like substance in the grout lining the far wall in the shower. The black like substance extends up the corner of the wall approximately 12 inches long. The black like substance was in both corners of the shower. On March 27, 2024 at 9:29 AM, V16 Maintenance Director stated, the black like substance was a housekeeping issue. If they couldn't get the substance off then he would get involved to re-tile the shower. On March 27, 2024 at 9:43 AM, V14 Housekeeper stated, she was aware of the black like substance in the shower. She tried to clean it off with bleach but it would not come off. She needs better cleaner. On March 27, 2024 at 9:46 AM, V10 Environmental Director stated, V17 Housekeeper told him a week ago…

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 shower to a resident that needs extensive assist with Activities of Daily Living (ADL's) to 1 of 3 residents reviewed for ADLs in the sample of 12. The findings include: R1's facility assessment dated [DATE] show R1 has no cognitive impairment. On 3/27/24 at 8:45 AM, R1 was in the dining room. R1 said she does not get her shower consistently. R1 said she had a shower 3 days ago but prior to that, R1 said she did not get a shower for at least a week. R1 said she tried to request a shower at that time but she felt ignored. R1 said she told her sister in law. On 3/27/24 at 9:30 AM, V17 (R1's sister in law) said R1 called her and told her that R1 was wanting shower but no one had offered a shower to her for more than a week. V17 said R1 needs a shower at least twice a week to make sure R1 was clean due to R1 being a bigger lady and needs her skin folds and creases be cleaned well. V17 said she called the facility management but did not…

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 free from significant medication errors. This applies to 2 of 4 residents (R1 & R5) reviewed for medications in the sample of 12. The findings include: 1. On 3/27/24 at 8:40 AM, R1 was wheeling herself back to her room and said she just had breakfast. R1's electronic medication administration record (EMAR) show R1 has an order of Insulin Lispro Solution- rapid acting insulin, inject 10 units subcutaneously with meals related to diabetes to be given at 8AM, 12PM and 6PM. The same document show on 3/27/24, R1 received her 8AM dose of 10 units Insulin Lispro at 10:07 AM ( 2 hours late and was also given 2 hours after breakfast.) On 3/27/24 at 12:30 PM, R1 was served lunch in her room. R1 said she already received her insulin before lunch. R1's EMAR show R1 received her 12PM dose of Insulin Lispro at 11:14 AM (just an hour from receiving the AM Lispro insulin dose and more than an hour before lunch) On 3/27/24 at 1 PM, V13 (Wound Nurse) said residents medications including should be administered at 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 resident received new prosthetics for 1 of 1 residents (R2) reviewed for prostheses in the sample of 4. The findings include: On 3/14/24 at 9:41 AM, R2 was sitting in bed. R2 had amputations to both legs below the knee. R2 stated I'm trying to get new prostheses so I can walk again and get out of here. Those are my old ones over there (pointed to prostheses on floor by the wall of his room) and one of them the metal on top is broke so I can't wear them. Once I get new prostheses I can work with therapy. A vendor came once last June or July of 2023 and did measurements and that's it, I don't know what's going on with it. On 3/14/24 at 10:00 AM, V1 Administrator and V2 Director of Nursing said a vendor came out and measured R2 for new prostheses and sent forms to V6 MD to fill out and submit to the insurance. V2 said the insurance company denied R2 due to non-compliance per V6. On 3/14/24 at 11:43 AM, V2 said the insurance forms were not filled out by V6 due to R2 not being compliant with restorative…

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 physician ordered medications were administered as prescribed for 1 of 1 resident (R1) reviewed for medication administration in the sample of 3. The findings include: R1's face sheet printed on 2/27/24 showed diagnoses including but not limited to diabetes mellitus, schizoaffective disorder, bipolar type, dementia, insomnia, and auditory hallucinations. R1's facility assessment dated [DATE] showed no cognitive impairment. On 2/27/24 at 8:40 AM, V5 (R1's insurance coordinator) stated she was reviewing R1's file and noted documentation related to R1 being sent to the local emergency room for a medication error. V5 said she asked R1 about the incident and he relayed the event did occur. R1 said he received another resident's medications and felt dizzy afterward. V5 stated R1 reported a headache, stomach ache, and nausea as well. On 2/27/24 at 11:00 AM, R1 stated he received the wrong pills a few weeks ago. R1 said it made him feel stressed out and…

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

Based on interview and record review the facility failed to provide sufficient staff to meet the needs of residents. This had the potential to effect all 158 residents. The findings include: The facility's 12/5/23 application for Medicare and Medicaid showed 158 residents in the facility. On 12/05/23 11:38 AM, R141 said there isn't enough staff here. I can't walk, and I've laid in a soiled bed for 3 days. I have a clear mind. Weekends are the worst. On 12/06/23 at 09:07 AM, R135 said there's not enough staff. Sometimes there is no aide in my hall. It takes a while to get care. I have sat soiled for 4-5 hours waiting for help. It makes me feel like I'm being ignored and not getting what I'm paying for. At 10:51 AM, V8 CNA said, No there's not enough staff to care for residents. We split hallways and work doubles. Staff are assigned 1 1/2 hallways. Residents wait longer for help. I have worked when there were only 3 CNAs and 3 nurses on duty. I started in April 2023. It's better now than then. At 01:23 PM, V6 CNA Scheduler said we currently have 6 CNA vacancies. I schedule at least 11…

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

Based on observation, interview, and record review the facility failed to maintain a medication refrigerator in manner to safely store medications. This affects all residents residing in the facility. The findings include: The CMS 671 Form dated 12/5/23 showed the facility census was 158. On 12/6/23 at 2:00 PM, V2 (DON - Director of Nursing) said the facility does not have a convenience box. V2 said we use an automated medication delivery system and all nurses have access to it. V2 said there is only one automated medication delivery system for the entire facility at this time. V2 said the automated medication delivery system is used by the nurses to obtain common medications for residents that may be missing a medication or a new admission that needs a dose before the pharmacy delivery. At 2:15 PM, V2 opened the first floor medication room. Inside there was an automated medication delivery system with a locked, mini-refrigerator attached. The mini-refrigerator had a lock panel across the front that was released when medications stored in the refrigerator are accessed. On the…

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

Based on observation, interview, and record review the facility failed to ensure dietary staff were wearing hair nets to prevent cross-contamination. This has the potential to affect all the residents residing in the facility. The findings include: The CMS 671 Form dated 12/5/23 showed the facility census was 158. On 12/5/23 at 9:07 AM, V14 (Dietary Aide) was loading dirty dishes into the dishwasher. V14 was wearing gloves and an apron, but no hair net. V14 was moved about the dish room, kitchen, and dry storage room during the initial kitchen tour. At 11:07 AM, V14 passed the kitchen prep area. Spaghetti noodles were cooking on the stove in two large pans. There were cookie sheets of parmesan, garlic toast sitting on the prep table. V14 walked passed the bread to obtain a tray of drinks from the walk-in cooler. V14 did not have a hair net on. V14 took the tray of drinks into dining room. V14 returned to the kitchen and obtained items from the cooler. V14 returned to the kitchen and walked past the food prep and back into the walk-in cooler. V14 moved about the kitchen and steam…

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 implement its policy for self-administration of medications when a resident (R40) was allowed to keep nebulizer treatments at the bedside. This applies to 1 of 1 (R40) residents reviewed for self-administration of medications. The findings include: R40's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Schizoaffective disorder, anxiety, and personality disorder. R40's 10/24/23 Annual Minimum Data Set (MDS) showed she was cognitively intact with a score of 13 out of 15. R40's December 2023 Medication Administration Record showed an order for Ipratropium-Albuterol (medications used to open a person's airway) to be given three times a day. The order does not state to be left at the bedside. On 12/05/23 at 1:17 PM R40 stated she had just finished a nebulizer treatment. On R40's bedside table was a sealed plastic vial labeled Ipratropium/Albuterol.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a resident with a bariatric bed for 1 of 1 resident (R139) reviewed for accommodation of needs in the sample of 32. The findings include: R139's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include Schizoaffective Disorder, Generalized Anxiety Disorder, Morbid (Severe) Obesity, Type 2 Diabetes Mellitus, and Peripheral Vascular Disease. R139's Weights and Vitals Summary showed his weight to be 431.2 lbs on 11/7/23. On 12/05/23 at 1:07 PM, R139 was laying in his bed. R139 said he could use a bigger bed. R139 had a regular twin size bed. The front and back legs of the bed were both pushing significantly outward due to the weight of R139's body. On 12/07/23 at 9:56 AM, V22 Restorative LPN (Licensed Practical Nurse) said he assesses the residents for adaptive equipment and monitors resident weights monthly. V22 said if a resident needs a bariatric bed they would be able to get a bariatric bed but it is a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offload pressure for a resident with a Stage 4 pressure injury for 1 of 3 residents (R135) reviewed for pressure in the sample of 32. The findings include: R135's face sheet showed a [AGE] year-old male with diagnosis of an unstageable pressure ulcer to the left heel, Type 2 Diabetes, major depressive disorder, anxiety disorder, and presence of cardiac and vascular implant and graft. , On 12/05/23 at 11:32 AM, R135 was in bed with both heels touching the bottom sheet of the bed. There was a dressing to the left heel with moderate thin brown drainage noted to the dressing and bottom sheet. All R135's toes were absent, and he was able to lift both feet off the bed with effort when asked. R135 was alert and oriented X3. At 1:58 PM, R135 was in the same position as earlier, both heels were resting on the bed and the wound drainage remained present. On 12/06/23 at 09:07 AM, R135 was in bed with both heels resting on the mattress. There was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store a resident's nebulizer mask in a clean area. This applies to 1 of 1 residents (R40) reviewed for respiratory services in the sample of 32. The findings include: R40's admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Schizoaffective disorder, anxiety, and personality disorder. R40's Order Summary Report (Physician Order Sheet) showed an order for two types of nebulizers: a combination nebulizer with Ipratropium/Albuterol to be given three times a day and an as needed nebulizer of only Albuterol. (Medications to open a person's airway.) R40's Physician Orders showed an order for levofloxacin (antibiotic) to start on 11/22/23 daily for 14 administrations for lung infiltrates. On 12/05/23 at 1:17 PM, R40 had just finished a nebulizer treatment and her nebulizer mask was sitting on her bedside table. R40's bedside table had several large,…

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 not borrowed from another resident during medication administration for 2 of 4 residents (R155, R101) reviewed for medication administration in the sample of 32. The findings include: On 12/6/23 at 7:57 AM, V11 (Registered Nurse - RN) obtained R155's blood sugar. R155's blood sugar was 252, requiring V11 to administered regular insulin per a sliding scale. V11 looked through the top right drawer of the medication cart. V11 was unable to locate regular insulin for R155. V11 stated, I float, so I'm at the mercy of this cart. I'm going to have to borrow insulin for [R155]. V11 picked up a plastic bag labeled with R101's name on it. There was an unopened, vial of regular insulin with R101's pharmacy label affixed to the vial. V11 removed the vial cap and drew up 6 Units of regular insulin to administer to R155. V11 returned R101's regular insulin vial to the top right drawer with R101's label remaining on the vial (V11 just used this vial to draw insulin for R155). V11 did not go to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer pneumonia vaccinations to 2 of 5 residents (R37, R94) reviewed for immunizations in the sample of 32. The findings include: 1. R37's face sheet showed a [AGE] year-old male with diagnosis of chronic obstructive pulmonary disease, dementia, legal blindness, schizophrenia, bipolar disorder, hypertension, and Type 2 Diabetes. R37's face sheet showed admission to the facility on 9/26/2005. On 12/07/23 at 11:08 AM, V17 Infection Preventionist (IP) said R37 had not received a pneumonia vaccination since the 2009 dose. V17 was unable to specify what vaccine variant R37 received in 2009. R37's physician order sheet showed a 7/29/2014 order for pneumonia vaccine every 5 years for over 65 (years of age) unless refused or contraindicated. R37's 10/12/23 pneumonia vaccine consent showed consent for the vaccination was given by his health care surrogate. This same consent form showed R37's last pneumonia vaccine was given on 11/16/09. The specific vaccine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide COVID-19 vaccinations after consent was received for 2 of 5 residents (R37, R94) reviewed for immunizations in the sample of 32. The findings include: 1. R37's face sheet showed a [AGE] year-old male with diagnosis of chronic obstructive pulmonary disease, dementia, legal blindness, schizophrenia, bipolar disorder, hypertension, and Type 2 Diabetes. R37's face sheet showed admission to the facility on 9/26/2005. On 12/07/23 at 11:08 AM, V17 Infection Preventionist (IP) said the facility was in a COVID outbreak status from 9/29/23-11/15/23. V17 said R37 had not received a COVID booster after consent had been obtained on 12/1/23. R37's immunization record showed the last COVID vaccine administered was on 11/15/22. A facility COVID Vaccination Policy was requested twice. V17 confirmed the 5/23 Vaccination and Reporting Policy was all the facility utilized. This one page, three lined procedure showed the purpose of the policy was to ensure all…

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 administer and document medications for 4 of 5 residents (R1, R2, R4, and R5) reviewed for medications in the sample of 5. The findings include: On 11/21/23 at 2:09 PM, R1 said the nurses are inconsistent about giving him his medications. R1 said sometimes they come and give you medications and sometimes you have to go find them to get your medications. On 11/21/23 at 11:13 AM, R2 said she receives her medications about 95 percent of the time. R2 said she supposes they didn't have a nurse available to give them during the times she did not receive them. R2 said she doesn't have life threatening meds and can make it without receiving them. On 11/21/23 at 2:21 PM, R4 said she has missed getting her medications a couple of times. On 11/21/23 at 2:57 PM, R5 was in his room repeatedly throwing eating utensils up to the ceiling. R5 appeared very agitated and was not approached for an interview. On 11/21/23 at 2:00 PM, V3, Licensed Practical Nurse (LPN), 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 ensure 2 of 3 residents (R1 and R3) were free of resident to resident abuse in the sample of 3 reviewed for abuse. The findings include: On 10/5/23 at 3:11 PM, V1, Administrator, said he watched the video from 9/7/23. V1 said the video showed R1 walking down the hall carrying his cup of coffee. R1 and R2 passed each other in the hall, and R2 turned and hit R1. V1 said R2 hit R3 while he was asleep in his chair on 9/28/23. On 10/10/23 at 12:20 PM, V1 said he reviewed video from 9/28/23. V1 said the video showed R2 coming out of the elevator. R2 walked right up to R3 and hit him on the shoulder. V1 said it was an easy investigation because it was witnessed. V1 said he acknowledges both incidents happened and were inappropriate. On 10/5/23 at 3:01 PM, R1 said R2 hit him a couple of times and he has no idea why. R1 said he got a bump on his cheek, but did not have any other injuries R1 said he feels OK now, but would not feel safe if R2, got that way again. On 10/5/23 at 2:36 PM, V5, Social Services (SS) Director, said R2 hit…

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

Based on interview and record review, the facility failed to investigate an allegation of resident to resident abuse for 1 of 3 residents (R1) in the sample of 3 reviewed for abuse. The findings include: On 10/5/23 at 3:11 PM, V1, Administrator, said he watched the video from 9/7/23. V1 said the video showed R1 walking down the hall carrying his cup of coffee. R1 and R2 passed each other in the hall, and R2 turned and hit R1. V1 said R2 hit R3 while he was asleep in his chair on 9/28/23. V1 said those were the only two abuse allegations he investigated in September 2023. On 10/10/23 at 12:20 PM, V1 said he investigates every allegation of abuse. V1 said an abuse investigation includes separating the residents, finding out where it happened, and reviewing video if there are cameras in the area. V1 said he interviews the residents involved and asks them if they want to notify the police, interviews residents in the vicinity, and the nurses notify family and the doctor and assess the residents for injuries. V1 said he makes a determination of was it an accident or on purpose. V1 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.