Pa Peterson At The Citadel

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure as needed anti-anxiety medications had a stop date for two of five residents (R66, R104) reviewed for chemical restraints in the sample of 24. The findings include: 1. R66's admission Record shows she was admitted to the facility on [DATE], with diagnoses including dementia, major depressive disorder, Alzheimer's disease, anxiety disorder, unspecified psychosis, insomnia, and difficulty walking. R66's Order Summary Report dated May 19, 2025, shows an order for clonazepam 0.5 mg by mouth every eight hours as needed (PRN) for anxiety ordered on December 27, 2024, and an order for lorazepam give 0.25ml by mouth every four hours as needed for anxiety ordered on January 2, 2025. Neither order has a stop date. 2. R104's admission Record shows she was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and insomnia. R104's Order Summary Report dated May 20, 2025, shows an order for lorazepam 0.25ml by mouth every four hours…

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 activities of daily living (ADL) assistance was provided for dependent residents for three of 24 residents (R16, R34, R93) reviewed for incontinence care in the sample of 24. The findings include: 1. R16's admission Record dated May 19, 2025, shows she was admitted to the facility on [DATE], with diagnoses including unspecified psychosis, Meniere's disease, and osteoarthritis. R16's Care Plan initiated March 17, 2025, shows, Clean peri-area with each incontinence episode. Keep skin clean and dry. R16's Minimum Data Set (MDS) dated [DATE], shows she is occasionally incontinent of bladder and frequently incontinent of stool. R16 is dependent on staff for toileting hygiene and mobility. On May 19, 2025, at 9:39 AM, V14 (Certified Nursing Assistant) CNA said that R16 was not cleaned up for the day yet. V14 said that R16 had breakfast in bed. R16's incontinence brief was completely saturated with dark urine. 2. R34's admission Record…

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 assess and implement treatment interventions for pressure wounds, and failed to ensure pressure relieving interventions were in place for 3 of 8 residents (R77, R365, R362), reviewed for pressure wounds in the sample of 24. The findings include: R365's admission Record dated 5/19/25 shows he was most recently admitted to the facility on [DATE]. R365's After Hospital Care Plan dated 5/16/25 shows an order under the heading How Should You Care for your Wound as follows: Buttocks: zinc paste apply daily and as needed. R365's Nursing Admission/re-admission assessment dated [DATE] at 4:38 PM shows R365 has a pressure wound of his sacrum. R365's TAR (treatment administration record) for 5/1/25 to 5/31/25 shows no treatment was initiated for R365's sacral wound as of 5/21/25. R365's Order Summary Report dated 5/19/25 shows no wound treatment/care orders for R365's sacrum. R362's admission record dated 5/19/25 shows he was admitted to the facility on [DATE].…

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 splints were in place for residents with contractures for 2 of 5 residents (R30, R12) reviewed for limited range of motion in the sample of 24. The findings include: 1. R30's Physician Order Sheet (POS) show R30 has diagnoses of stroke with left sided paralysis. R30's facility assessment dated [DATE] show R30 is alert and able to verbalize his needs. R30 has limited range of motion due to history of CVA (stroke). The same assessment show R30 has no behaviors of rejection of care. On 5/19/25 at 10 am, R30 was sitting in his wheelchair in his room. R30's contracted left hand- (fingers were all curled/clenched towards the palm) was in his lap. R30 said no one does anything to his left hand, then used his right hand to lift his contracted left hand to show this surveyor. R30 said he has a splint that no one applies. R30 said no one exercises his contracted left arm. At 1:12 PM, R30 was sitting in his wheelchair in his room watching TV.…

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 was transferred safely for 1 (R66) of 24 residents reviewed for safety/supervision in the sample of 24. The findings include: R66's admission Record dated May 19, 2025, shows R66 was admitted to the facility on [DATE], with diagnoses including dementia, major depressive disorder, primary generalized osteoarthritis, Alzheimer's disease, anxiety disorder, fatigue, displaced right femur fracture, difficulty walking, and non displaced fracture of right and left little finger. R66's Fall Scale dated March 17, 2025; shows she is a high risk for falling. R66's Care Plan last revised on April 12, 2022, shows R66 has an activities of daily living (ADL) self-care performance deficit related to impaired mobility, impaired cognition. R66's care plan shows R66 requires a limited one assist for bed mobility and transferring. R66's Minimum Data Set (MDS) dated [DATE], shows R66 requires substantial/maximal assistance for transferring…

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 R44's steel oxygen cylinders were stored to prevent damage to the cylinders for 1 of 5 residents (R44) reviewed for respiratory services in the sample of 24. The findings include: On 05/19/25 at 12:04 PM, R44 was lying in bed. There was an oxygen tank leaning against the wall in her closet area. The oxygen tank was not secured to keep the cylinder upright. Leaning against the bedside table, near the head of R44's bed, was a second oxygen tank. The oxygen tank was not secured to keep the cylinder upright. On 05/19/25 at 12:05PM, V8 LPN-Licensed Practical Nurse said, when R44 is up in her wheelchair the oxygen tank is attached to the back of the wheelchair. When the oxygen tank is not in use it should be stored in the oxygen cylinder storage room. The facility's Oxygen Safety Policy effective date February 2019 shows, all oxygen cylinders must be stored in racks with chains, sturdy portable carts, or approved stands and never left free-standing or in any resident room or living area.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview and record review the facility failed to ensure medications were legibly labeled and dated when opened for 2 of 2 residents (R24 R18) reviewed for medication storage in the sample of 24. The findings include: On [DATE] at 8:10 AM, this surveyor and V8 (License Practical Nurse-LPN) checked the medication cart on the east ground floor. R24's pain medication-Morphine Sulfate 100 mg/5 ml was opened but not dated when it was opened. The controlled drug receipt shows R24's date of delivery from the pharmacy was [DATE]. V8 said R24 is on palliative care and needs the morphine for pain. V8 said she will call R24's physician and reorder R24's Morphine. At 8:20 AM, this surveyor and V9 (LPN) checked the medcart on the west ground floor. R18 had a medication of Diazepam 1 ml (5mg) every 10 minutes for seizure. The label of the medication was not legible and was almost falling off. The medication was opened but not dated when it was opened. The medication expiration date was [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer a resident the pneumonia vaccination which applies to 1 of 5 residents (R36) reviewed for vaccinations in a sample of 24 The findings include: R36's Facility assessment dated [DATE] showed R36 is a seventy-seven-year-old male resident admitted to the facility on [DATE]. R36's electronic medical record showed R36 refused the pneumococcal polysaccharide vaccine (PPSV) 23 and the pneumococcal conjugate vaccine (PCV) 13 on 6/2/21. On 5/20/25 at 11:20 AM, V25 Infection Control Preventionist (ICP) stated the facility follows the Centers for Disease Control (CDC) guidelines for vaccinations which included the pneumonia vaccine. V25 stated the current pneumonia vaccinations the facility offers is the PCV 20. Residents should be offered immunizations upon admission and when they are eligible to receive a vaccination. V25 stated they had not talked with R36 prior to this interview. The facility did not produce any documentation R36 had been offered a…

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

Based on interview and record review, the facility failed to conduct a thorough investigation and failed to obtain and/or maintain documentation of a thorough investigation of monetary misappropriation for 1 of 24 residents (R364) in the sample of 24 reviewed for abuse. The findings include: On 5/19/25 at 10:50 AM, R364 said she knows she had $120 in her purse because she checked her purse for money around 6:00 PM on Sunday (5/11/25) because she was going to order pizza but didn't. R364 said on 5/12/25 she went to the bathroom to get ready and V7, Certified Nursing Assistant (CNA) was in her room. R364 said when she finished getting dressed, she checked her purse and only had $20 left. R364 said she knows there was a CNA in her room during the night shift from 5/11/25 to 5/12/25. On 5/20/25 at 10:42 AM, V1, Administrator, said R364 told him she had a feeling V7, Certified Nursing Assistant (CNA) took money from her purse around 8:30 AM (on 5/12/25). V1 said he interviewed some night shift staff on the phone but did not write down or type their interviews regarding R364's allegations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with oral and/or denture care for one (R7) of three residents reviewed for activities of daily living (ADL); and the facility failed to follow its policy and procedures by not ensuring that a resident with a self-care deficit (R7) received the necessary assistance to maintain oral hygiene. The findings include: Review of R7's face sheet indicated resident admitted to the facility on [DATE] with a past medical history not limited to: dementia, type 2 diabetes mellitus, peripheral vascular disease, mild cognitive impairment, anxiety, hypertension, and history of infectious and parasitic diseases. Review of R7's Minimum Data Set, Section C for Cognitive Patterns (page 9) dated 11/15/2024 documented Brief Interview for Mental Status (BIMS) score of 5/15 which indicates impaired cognition. Section GG for Functional Abilities (page 21) dated 11/15/2024 documented that resident requires partial to moderate assistance with oral…

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

Based on observation, interview, and record review the facility failed to ensure a homelike environment by having wallpaper falling down that had a black substance on it for 2 of 4 residents (R1 and R6) reviewed for homelike environment in the sample of 4. The findings include: On 12/10/24 at 8:20 AM, R1 and R6 were roommates and were in their room. There was a rectangular piece of wallpaper next to the window that was falling down. The piece of wallpaper was visible from the hallway and was not obstructed by the window curtains. The wallpaper was white and ran from the top of the window to the bottom of the window. The width was approximately 17 inches, and the height was approximately 4 feet. The top of the wallpaper was no longer attached to the wall. The unattached portion ran the length of the window (about 4 feet) and was folded over onto itself. Roughly half of the piece of wallpaper was unattached and folded over on itself. The unattached part of the wallpaper would have been next to the window. The loose part of the wallpaper had a black substance that ran along the edge 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 controlled medications were documented as administered in the narcotic reconciliation binder for 8 of 9 residents (R4, R6-R12) reviewed for controlled medications in the sample of 13. The findings include: On 11/19/2024 at 8:48 AM, V4 (Registered Nurse-RN) said he was preparing the medications for the last resident in his AM medication pass. On 11/19/2024 at 9:18 AM, this surveyor conducted a medication reconciliation count with V4 (Registered Nurse-RN) for the controlled medications in the ground floor east medication cart. During the medication count, the following residents' medications were not documented as administered in the narcotic reconciliation binder on 11/19/2024: R4's Tramadol Hydrochloride 50 mg (milligram)(for moderate to severe pain), the narcotic binder showed 25 pills, and the medication card had 24 pills in the card. R6's Norco 5/325 mg (pain medication), the narcotic binder showed 28 pills and there were 27 pills in the medication card. R6's Clonazepam 0.5 mg (anti-anxiety…

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 misappropriation of medications did not occur for 1 of 3 residents (R2) reviewed for misappropriation of medications in the sample of 13. The findings include: R2's admission Record, printed by the facility on 11/19/2024, showed he had diagnoses including, but not limited to, methicillin resistant staphylococcus aureus infection, a stage 4 pressure ulcer of left heel, personal history of malignant neoplasm of bladder, peripheral vascular disease, weakness, and localized edema. R2's Medication Administration Records (MARs) for August 2024 and September 2024 showed an order for Levaquin 750 mg daily for wounds, for seven days. The MARs showed R2 received the Levaquin as ordered. On 11/19/2024 at 8:48 AM, V4 (Registered Nurse/RN) was observed at the medication cart preparing medications for a resident. On 11/19/2024 at 10:45 AM, V1 (Administrator) said the only allegation the facility received regarding a nurse taking residents' medications involved V4. V1 said V5 (RN) and V9 (Nurse) reported to him on 10/2/2024 that…

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 misappropriation of medications to the Illinois Department of Public Health for 1 of 3 residents (R2) reviewed for misappropriation of medications in the sample of 13. The findings include: On 11/19/2024 at 10:45 AM, V1 (Administrator) said an allegation was made on 10/2/2024 by V5 (Registered Nurse-RN) and V9 (Nurse) that V4 (RN) had taken medications. V1 said he tried calling V4, however, V4 had already left for the day. V1 said he notified V3 (VP of clinical operations), and she followed up with the investigation. On 11/19/2024 at 11:03 AM, V3 said V1 informed her of the allegation on 10/2/2024 around 7:00 PM. V3 said she asked V1 if she could follow-up on the allegations the next morning as long as no residents were in danger. V3 said she interviewed V5 and V9 regarding the allegations. V3 identified the medication as R2's Levaquin (an antibiotic) V3 said she spoke with V4 who said he did not take any medication. V3 said she did not report the allegation to IDPH (Illinois Department of Public…

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 conduct a thorough investigation of an allegation of misappropriation of medication for 1 of 3 residents (R2) reviewed for misappropriation of medications in the sample of 13. The findings include: On 11/19/2024 at 10:45 AM, V1 (Administrator) said on 10/2/2024 V5 (Registered Nurse-RN) and V9 (Nurse) reported an allegation of V4 (Registered Nurse-RN) taking medications. V1 said he tried calling V4, however, V4 had already left for the day. V1 said he informed V3 (VP of Clinical Operations) about the allegation and she was going to follow-up with the investigation the following morning. On 11/19/2024 at 11:03 AM, V3 (VP of Clinical Operations) said V1 informed her of the allegation on 10/2/2024 around 7:00 PM. V3 said she asked if she could follow up on the allegation the next morning as long as there was no danger to any residents. V3 said she interviewed V5 and V9 the next morning and they told her that they thought they saw V4 popping pills out of a medication card and putting them in his pocket. V3 said 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 ensure controlled medications were stored under a double lock in the medication room for 2 of 9 residents (R6 and R13) reviewed for controlled medications in the sample of 13. The findings include: On 11/19/2024 at 9:34 AM, the refrigerator in the medication room containing controlled medications was not locked. The lock to the refrigerator was resting on the latch, however, the lock was open. 10 ml (milliliters) of Lorazepam 2 mg/ml (milligrams per milliliter) for R6 were in the unlocked refrigerator as well as an opened bottle containing 1.5 ml of Lorazepam 2 mg/ml for R6. A container with 30 ml of Lorazepam 2 mg/ml was in the unlocked refrigerator for R13, as well as 2 ABHR suppositories (a compounded product using four different medications: lorazepam, diphenhydramine, haloperidol and metoclopramide (used to treat nausea and vomiting). Lorazepam is a schedule IV-controlled medication. V4 said the refrigerator should be kept locked when a nurse is not in the medication room. On 11/19/2024 at 9:43 AM, V2…

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

Based on interview and record review the facility failed to ensure that staff follow the Abuse Prevention Policy. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 3. The findings include: The undated facility policy entitled Abuse Prevention Training Program Protocol states, The objective of the Abuse Prevention Program is to comply with the seven step approach to abuse and neglect detection and prevention. This same policy also states, The direct care staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. On 10/17/24 at 11:40 AM V4 (Corporate Nurse) stated, (V4- Activity Aide) had a suspicion but she didn't come to us right away. She told (V3- Activity Aide) about it. On 10/17/24 at 9:44 AM, V4 (Activity Aide) stated, I went in (R1's) room to get him for the activity and (R2) was next to (R1). (R1) was in the bed. I asked if (R1) was going to go to the activity and (R2) said, 'No (R1) wants to take a nap.' (R2) was acting strange as he was tucking…

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

Based on interview and record review the facility failed to ensure that staff report suspicions of sexual abuse to administration in a timely manner. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 3. The findings include: The facility Reported Incident dated 10/15/24 states, Activity Staff alleged that when they checked on resident (R1) to see if he was attending an activity, staff observed (R2) putting a blanket over (R1) and tucking in the blanket . The activity staff were suspicious of the gesture and reported to the administrator that (R2) may have touched (R1) in his private areas. Staff denied seeing (R1) touch (R2). Both residents were fully clothed with pants on. On 10/17/24 at 9:44 AM, V4 (Activity Aide) stated, I went in (R1's) room to get him for the activity and (R2) was next to (R1). (R1) was in the bed. I asked if (R1) was going to go the activity and (R2) said, 'No (R1) wants to take a nap.' (R2) was acting strange as he was tucking the blankets in around (R1)- like he had just been caught doing something he shouldn't. When (R2) saw…

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 Power of Attorney regarding a reported fall, new onset of right ankle swelling, and an Xray order. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 4. The findings include: On 10/15/24 at 11:20 AM, R1 was sitting at a dining table waiting for the noon meal. R1 was pleasant and oriented to person and place. R1's right ankle was swollen when compared to the left ankle. R1's 8/22/24 Quarterly Minimum Data Set (MDS) showed she had severe cognitive impairment with a Brief Interview for Mental Status score of 7 out of 15. The MDS showed she required supervision for ambulating 150 feet. On 10/15/24 at 11:20 AM, R1 stated her ankle was swollen as a result of a fall. R1 stated the fall happened a few months prior. On 10/15/24 at 3:00 PM, V5 stated she was notified, on 10/9/24, that R1 had a swollen right ankle. V5 stated she noted R1 did have a swollen ankle and she asked R1 the cause of the swelling to which R1 replied she had fallen the day prior (10/8/24). 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.

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 had a change of condition received services timely for suspected urinary tract infection. This applies to 1 of 4 residents (R1) reviewed for quality of care in the sample of 4. The findings include: R1's face sheet shows she is a [AGE] year-old female with diagnosis including congestive heart failure, anorexia, type 2 diabetes, major depressive disorder, atrial fibrillation, hearing loss, generalized anxiety, kyphosis, and history of pulmonary embolism. On 10/7/24 at 12:54 PM, V11 (R1's POA) said her mom (R1) has had a change in the last couple of weeks. She has been more lethargic and not her normal self. On 9/23/24 a care conference was held, and she expressed her concerns regarding the change in her mom. She requested labs and urinalysis (UA). She followed up with V3 (Ground Floor Manager) regarding the labs and was told they were not done yet. No one seems to know when my mom started to have this change of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident with significant weight loss received the recommended nutritional supplements. This applies to 1 of 4 residents (R1) reviewed for weight loss in the sample of 4. The findings include: R1's face sheet shows she is a [AGE] year-old female with diagnosis including congestive heart failure, anorexia, type 2 diabetes, major depressive disorder, atrial fibrillation, hearing loss, generalized anxiety, kyphosis, and history of pulmonary embolism. On 10/7/24 at 8:27 AM, R1 was observed in bed with her eyes closed. She did not respond to stimuli after several attempts of calling out her name. An empty water mug was on her bedside table. The meal tray cart was located in the hallway. R1's breakfast tray with her diet card was on the cart, with an unopened milk carton, serving of eggs, toast and bowl of oatmeal. R1's meal tray appeared not eaten and there was no signs of spillage around the bowl. There was not another breakfast tray…

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 an intravenous antibiotic was administered and failed to administer medication at the scheduled times for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 10. The findings include: On 9/24/24 at 10:36 AM, R1 was lying in bed. R1 said he had major surgery on his back and was on antibiotics for an infection. R1 said there were issues with the IV (intravenous) antibiotics. R1 said the IV was removed yesterday and he had completed the medications, but not without issues. R1 said his antibiotics were late multiple times, the nurse would leave the IV connected long after the medication was finished, and there were times that he didn't even know if he got the antibiotic. R1's Facesheet printed 9/24/24 showed diagnoses to include, but not limited to: chronic blood clots in his femoral artery; generalized muscle weakness; bacteremia; extradural and subdural abscesses; osteomyelitis of the thoracic vertebrae (spine); opioid dependence;…

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 daily dressing changes were completed as ordered, and failed to ensure as needed dressing changes were completed when a dressing was loose for 2 of 3 residents (R3 & R4) reviewed for dressings in the sample of 8. The findings include: 1. On 9/10/24 at 3:18 PM, V7 (Registered Nurse/RN-Wound Nurse) went into R4's room with the surveyor to do a check on R4's right calf skin tear and dressing. R4's dressing was coming off around some of the edges and was wrinkled up on one side. V7 stated R4's dressing was coming undone and was dated 9/8/24. V7 removed R4's dressing and she had a small skin tear to the calf area of her right leg. V7 stated dressings should be done as ordered and documented on the TAR (Treatment Administration Record). The Physician Orders dated 9/11/24 for R4 showed an order entered on 9/4/24, skin tear right posterior leg - cleanse with wound cleanser. Pat dry. Apply skin prep peri wound. Apply xeroform to wound bed. Cover with a transparent film dressing. Complete treatment three times…

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 give a resident an as needed nebulizer treatment when he was wheezing for 1 of 3 residents (R1) reviewed for medications and respiratory treatments in the sample of 8. The findings include: On [DATE] R1 could not be observed at the facility; R1 died on [DATE]. The admission summary dated [DATE] at 5:46 PM for R1 showed, Wife called back at 5:26 PM and gave verbal consent to treat patient. Patient lung sounds clear with light wheezing bilaterally, patient unaware & disoriented x 4 (person, place, time, & situation) On [DATE] at 8:33 AM, V2 (Director of Nursing/DON) stated, if R1 was wheezing she would have first assessed him, then obtained vital signs, he had oxygen so she would have asked him how he feels. V2 stated she would have given as needed nebulizer treatments if it was warranted. V2 stated if R1 had been wheezing he should have been given a nebulizer treatment. V2 stated she would have continued to monitor R1 to make sure he did not have any…

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 give a resident his evening medications for 1 of 3 residents (R1) reviewed for medications and respiratory treatments in the sample of 8. The findings include: On [DATE] R1 could not be observed at the facility; R1 died on [DATE]. The admission summary dated [DATE] at 3:03 PM for R1 showed, Patient arrived at facility from the hospital at 2:00 PM; patient is mentally altered. Tried contacting POA (power of attorney) at 2:34 PM for consent to treat. POA unavailable; left voicemail. The Medication Administration Record dated [DATE] for R1 showed on [DATE] at 5:00 PM, R1 was to receive the following medications: Entresto Oral Tablet 24-26 mg (milligrams), Metoprolol Tartrate 25 mg, and Hydralazine HCI 10 mg. R1's [DATE] MAR showed the medications were not signed of as being given. On [DATE] at 8:33 AM, V2 (Director of Nursing/DON) stated if R1 came in a 2:00 PM they would have put medication orders in after he arrived. V2 stated staff are to try to put 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 a resident with a diagnosis of dementia had individualized interventions with behaviors of agitation/restlessness while in bed. This applies to 1 of 3 residents (R1) reviewed for dementia care in the sample of 3. The findings include: R1's face sheet shows he is an [AGE] year-old male admitted to the facility on [DATE], with diagnosis including unspecified dementia with other behavioral disturbance, unsteadiness on feet, weakness, hypertension, heart disease, and systemic lupus. R1's Physician Order Sheets dated August 2024 shows orders for clonazepam 0.5 mg (milligrams) every 12 hours as needed for restlessness and agitation, Plavix 75 mg (antiplatelet) daily, and aspirin 81 mg daily. On 8/30/24 at 8:33 AM, R1 was observed in the dining room during the breakfast meal. R1 is thin, frail, with bony arms with multiple bruises and dark spots to his forearms. A foam dressing to his left elbow, a dark purple bruise above his left eyebrow…

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 clarify conflicting admitting orders for a resident who was re-admitted to the facility after hospitalization to ensure necessary care and services were provided. This applies to 1 of 3 (R1) reviewed for quality of care in the sample of 4. The findings include: R1's face sheet shows he is a [AGE] year old male re-admitted to the facility on [DATE] with diagnoses including critical illness myopathy, sepsis, unspecified protein calorie malnutrition, end stage renal disease, dependence on renal dialysis, chronic congestive heart failure, pneumonia, personal history of malignant neoplasm of prostate, history of venous thrombosis and embolism, multiple myeloma not having achieved remission, heart disease, presence of cardiac pacemaker, gastrostomy status and dysphagia. R1's Hospital After Visit Summary dated 8/3/24 shows he was hospitalized from [DATE] to 8/3/24, diagnosis: multifocal pneumonia likely due to aspiration. R1's medications list shows orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 4 of 4 residents (R1, R2, R3, and R4) reviewed for infection control in the sample of 4. The findings include: R1's admission Record dated 7/18/24 shows R1 was admitted to the facility on [DATE] and her diagnoses include, but are not limited to, acute osteomyelitis right ankle and foot, aftercare following surgery on the circulatory system, local infection of the skin and subcutaneous tissue, infection following a procedure, cellulitis of right lower limb, and surgical wound. R1's Order Summary Report dated 7/18/24 shows an order for treatment of R1's right inner thigh wound and orders for care of R1's right foot wound both dated 5/22/24. R2's admission Record dated 7/18/24 shows R2 was admitted to the facility on [DATE]. R2's Order Summary Report dated 7/18/24 shows R2 has open wounds to his right lateral ankle and right lateral lower leg. R3's admission Record dated 7/18/24 shows she was…

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

Based on observation, interview, and record review the facility failed to follow the chili recipe for the noon meal. This applies to all 127 residents. The findings include: The CMS 671 Long-Term Care Facility Application for Medicare and Medicaid dated July 8, 2024, shows, there are 127 residents residing in the facility. On July 8, 2024, at 11:38 AM, the chili was in the steam table to serve for the noon meal. The chili had ground beef, diced tomatoes and kidney beans in it. The chili had a beef broth base, soup like rather than a tomato base. At 11:48 AM, V25 [NAME] stated, she made the chili how she makes it at home. She did not put any tomato sauce in the chili because that is not how she makes her chili. She only put the meat, beans and diced tomatoes. V5 Dietary Manager stated, No, you have to follow the menu. On July 8, 2024, at 12:20 PM, R108 stated, the chili was watery. On July 8, 2024, at 12:32 PM, a test tray was provided to this surveyor. The chili looked like a soup with a beef broth. The chili tasted like a beef broth like soup and there were no green peppers, tomato…

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 ADL (activities of daily living) assistance to residents that required staff assistance for toileting and incontinence care for 7 of 25 residents (R101, R121, R113, R103, R9, R78, R24) reviewed for activities of daily living in the sample of 25. The findings include: 1. R101's resident assessment dated [DATE] showed R101 required staff assistance for repositioning, toileting, and toileting hygiene. On 7/8/24 at 9:05 AM, R101 was in bed, lying on her back. A urinary catheter bag hung off the side of R101's bed. R101 complained of pain to her buttocks and lower back. At 9:09 AM, V3 Certified Nursing Assistant (CNA) repositioned R101 on her side. V3 CNA pulled down the side of R101's incontinence brief, exposing R101's buttocks. R101's buttocks appeared red with multiple open areas noted to the skin of her buttocks. A nickel-sized wound was noted to R101's coccyx area with a scant amount of bleeding noted from the wound. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff removed their gloves and washed their hands to prevent cross contamination, failed to don personal protective equipment before entering an isolation room, and failed to implement Enhanced Barrier Precautions (EBP) for 6 of 25 residents (R9, R24, R58, R82, R101 and R103) reviewed for infection control in the sample of 25. The findings include: 1. On 7/8/24 at 1:50 PM, V18 and V19 (Certified Nursing Assistants) provided incontinence care to R24. R24 was turned to her side and there was a large amount of stool in her brief. V18 cleaned stool from R24's buttock area. R24 applied a cream to R24's buttock area and thighs that had open wounds present. R24 was then turned onto her back and incontinence care was provided to her front perineal area. V18 cleaned R24's front perineal area and applied cream to her bilateral groin area that had open wounds present. V18 then applied a new brief, adjusted R24's skirt, attached the mechanical…

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 was provided the COVID-19 vaccine. This applies to 1 of 5 residents (R113) reviewed for immunizations in the sample of 25. The findings include: R113's COVID-19 questionnaire dated March 20, 2024, shows, he was offered the COVID-19 vaccine. He accepted the offer and wanted the vaccine. R113's electronic medical record shows, he has not received the COVID-19 vaccine yet. He was admitted on [DATE] (4 months ago). On July 10, 2024, at 8:48 AM, V26 Infection Preventionist stated, R113 wanted the COVID-19 vaccine but has not been given it yet. She was not sure why. The facility's COVID-19 policy dated May 28, 2023, shows, Policy: The facility will conduct education, surveillance and infection control and prevention strategies to reduce the risk of transmission of COVID-19. The facility will follow and implement recommendations and guidelines in accordance with the Centers for Disease Control and Prevention (CDC), the State Department 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 splint was applied to a resident's left hand contracture for 1 of 2 residents (R11) reviewed for splints in the sample of 25. The findings include: On 7/8/24 at 8:40 AM, R11 was in the dining room for breakfast. R11 had a contracted left hand and there was no splint on his hand. R11 had a splint sitting on his windowsill in his room. There was a piece of paper on R11's wall that showed, On in AM and off at noon. At 9:58 AM, R11 was in his room. R11 did not have a splint on his left hand contracture. R11 stated, I'm supposed to wear it (splint), but they don't help me put it on. I haven't used in a long time. On 7/9/24 at 8:38 AM, R11 had no splint on his left hand contracture. On 7/10/24 at 9:10 AM, R11 was in his room and had no splint on his left hand. The splint was still sitting in the windowsill. On 7/10/24 at 9:10 AM, V17 (Certified Nursing Assistant) said that R11 does not have a splint for his hand, and she has never seen him wearing a splint. V17 said that typically therapy tells them if 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 residents were supervised while smoking. The facility also failed to ensure residents with a risk for aspiration pneumonia were supervised while eating. This applies to 2 of 25 residents (R5 and R83) reviewed for safety/supervision in the sample of 25. The findings include: 1. On July 8, 2024, at 3:40 PM, R5 was sitting approximately 6 feet from the front door of the facility smoking a cigarette. There were no staff supervising him while he was smoking. On July 9, 2024, at 9:41 AM, R5 stated, the facility knows he smokes. He goes out front to smoke most of the time. No one is out there with him when he is smoking. He also keeps his cigarettes and lighter with him. At the same time, R108 stated, R5 was not to be doing that. You'll get our smoking privileges taken away. You can't have your lighter on you, it has to be turned in. It's a fire hazard. On July 9, 2024, at 11:24 AM, V27 Activity Director stated, the residents can smoke on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure incontinence care was performed in a manner to prevent infections and failed to ensure indwelling urinary catheter bags were kept below the level of the bladder and off of the ground to prevent infection for 3 of 9 residents (R24, R103 and R158) reviewed for incontinence care and catheters in the sample of 25. The findings include: 1. On 7/8/24 at 1:50 PM, V18 and V19 (Certified Nursing Assistants) provided incontinence care to R24. R24's incontinence brief contained a large amount of stool. V18 sprayed perineal wash onto R24's front perineal area. V18 took a washcloth and cleaned R24's perineal area by wiping from the back to the front of the perineum. The washcloth had stool present on it after wiping. V18 did this multiple times while providing the incontinence care to R24. On 7/9/24 at 12:52 PM, V2 (Director of Nursing) said that when providing incontinence care, staff should always clean the front perineal area from back 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 administer medications as ordered. There were 24 opportunities with 7 errors resulting in a 24.14% error rate. This applies to 2 of 9 residents (R105, R113) observed in the medication pass. The findings include: 1. On 7/9/24 at 8:05 AM, V10 Licensed Practical Nurse (LPN) placed one tablet (tab) of Iron 325 mg (milligram), one tab of Loratadine 10mg, one tab of Furosemide 40mg, one tab of Lisinopril 10mg, and one tab of Potassium Chloride 20 meq (milliequivalents) into a medication (med) cup. V10 opened the package of a Lidocaine 5% patch, picked up the med cup of pills, and walked into R105's room. V10 LPN handed the cup of pills and Lidocaine patch to R105. R105 stated to V10, I put the patch on myself. V10 LPN then exited R105's room, without applying R105's Lidocaine patch or watching R105 take his medications. On 7/9/24 at 12:51 PM, V2 Director of Nursing (DON) stated there are no residents on the second floor (R105's floor) that can self-administer their medications. V2 stated nurses must watch residents…

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 label a multi dose insulin pen with an open and/or expiration date for one of one resident (R32) reviewed for medication labeling in the sample of 25. The findings include: R32's Order Summary Report dated July 10, 2024, shows an order for Lantus Solostar pen- 10 units at bedtime. On July 8, 2024, at 1:04 PM, there was a Lantus insulin pen that belonged to R32 that was delivered on June 1, 2024, with 200/300 units left, not labeled with an open date in the unit's medication cart. On July 9, 2024, at 8:26 AM, V20 RN (Registered Nurse) said the insulin pen should be labeled with the date it was opened. At 12:52 PM, V2 DON (Director of Nursing) said insulin pens should be labeled with an open date when they are opened. The facility's Insulin Reference Chart shows insulin Lantus pen is good for 28 days at room temperature.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer residents the pneumonia vaccine. This applies to 3 of 5 residents (R22, R82 and R113) reviewed for immunizations in the sample of 25. The findings include: R22's current immunization records show, she had the pneumococcal conjugate vaccine (PCV13) on June 15, 2015. The same record shows, she has had no other pneumonia vaccines. R82's current immunization records show, he had the pneumococcal conjugate vaccine on February 3, 2023. The same record shows, he has had no other pneumonia vaccines. R113's electronic medical record shows, no vaccines have ever been given. He was admitted on [DATE]. On July 10, 2024, at 8:48 AM, V26 Infection Preventionist stated, the facility offers both pneumonia (PNA) vaccines (PCV13 and Pneumococcal polysaccharide vaccine (PPSV23)). Both vaccines make up the PNA vaccine series. When a resident is admitted to the facility, they are offered the PNA vaccines. R22 can have PPSV23 anytime. She has not been offered or given…

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 (R1) representative of a change in condition and need to alter treatment. This applies to 1 of 5 residents reviewed for change in condition in the sample of 5. The findings include: R1's electronic face sheet printed on 6/10/24 showed R1 has diagnoses including but not limited to Parkinsonism, acute respiratory failure, pneumonia, chronic obstructive pulmonary disease, and hallucinations. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment and no behaviors. R1's care plan dated 6/6/24 showed, (R1) is noted to have a problem with cognition related to confusion. (R1) has used inappropriate verbal, and physical behaviors with facility personnel and residents at times, pushing walker into staff and residents around him. Patient will at times use foul language towards staff during caregiving, or redirection when behavior is happening. (R1) has been observed to engage in a variety of other behavioral symptoms…

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 protect 2 residents (R2, R3) from physical abuse by another resident. This applies to 2 of 5 residents reviewed for abuse in the sample of 5. The findings include: 1. R2's electronic face sheet printed on 6/10/24 showed R2 has diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction, emphysema, alcohol abuse, and repeated falls. R2's facility assessment dated [DATE] showed R2 has no cognitive impairment and no behaviors. R2's nursing progress notes dated 3/13/24 showed, Resident in dining room and told his roommate, (R4), that he was wearing his coat. (R4) walked over to (R2) and punched him in the right side of his face three times, while swearing and calling (R2) names. Staff separated residents. (R2) had a small amount of blood in the bottom of his mouth but was cleaned with water and the bleeding stopped. Administrator notified and both residents separated for the night. R4's facility assessment dated [DATE]…

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, document, and respond to behaviors for 1 of 5 residents (R1) reviewed for behavior management in the sample of 5. The findings include: R1's electronic face sheet printed on 6/10/24 showed R1 has diagnoses including but not limited to Parkinsonism, hallucinations, pneumonia, and acute respiratory failure. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment and has no behaviors. R1's care plan dated 4/17/24 showed, Resident has a diagnosis of hallucinations. Administer medications as ordered. No further interventions were listed in R1's care plan. R1's care plan dated 4/18/24 showed, The resident has a mood problem related to anxiety. Administer medications as ordered. No further interventions were listed in R1's care plan. R1's behavior and mood task documentation were reviewed for the past 30 days and showed no documentation until 6/8/24 of any behaviors for R1. R1's nursing progress notes showed, 6/6/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care for a dependent resident. This applies to 1 of 3 residents (R1) reviewed for ADLs in the sample of 4. The findings include: R1's electronic face sheet printed on 1/30/24 showed R1 has diagnoses including but not limited to periorbital cellulitis, hypertension, hypothyroidism, type 2 diabetes, and major depressive disorder. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and is dependent on staff for personal hygiene. On 1/30/24 at 8:30AM, V4 (R1's daughter) stated, I've been going every day to see her and now they are getting her up every day. She wasn't up for a month and a half. Her hair is so matted I'm going to have to cut it .They literally do nothing for her .There's nothing else to say except she gets horrible care at that place. On 1/30/24 at 8:35AM, R1 was sitting up in her reclining wheelchair sleeping. R1's hair was matted and tangled in the back. R1…

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 food temperatures were obtained prior to serving the meals. This failure has the potential to affect all 122 residents residing in the facility. The findings include: The Facility Data Sheet dated October 31, 2023, shows the facility census was 122 on October 31, 2023. The facility's Service Line Checklist for steam table #1 shows that food temperatures were taken on August 31, 2023, for breakfast and lunch and September 16, 2023, for breakfast and lunch. There were no other food temperatures logged from August 1, 2023-October 31, 2023. There were no temperatures taken on the steam table #2 Service Line Checklist from August 1, 2023-October 31, 2023. On October 31, 2023, at 9:00 AM, V10 Dietary Manager said if the facility is short staffed, they may not use steam table #2. Steam table #2 is for the first and second floor. Steam table #1 is for the ground floor and third floor of the facility. V10 said the steam table #2 was used this morning but there were no logs for temperatures taken. V10 said that temperatures…

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 homelike environment. This applies to 1 of 4 residents (R1) reviewed for homelike environment in the sample of 17. The findings include: On 10/10/2023 at 11:00AM, observations of R1's room were made. R1's room had an approximately 10 inch gouge on the back of the main door going into the room. The bathroom door at the bottom had damage as well. From the right corner of the bathroom door going towards the center of the door there was damage along the bottom of the door approximately six inches wide. Walking into the room on the right-hand side of the room on the wall closer to the windows there were 3 deep gouges in the drywall and paint, approximately one to two inches long and approximately a quarter inch deep behind the recliner. There were stains visible on the window curtains in the room. On the right window curtain there were two rust-colored stains approximately a half inch wide. On the left window curtain there was discoloration and circular stain marks present approximately 5 to 6…

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 neurological assessments were done after a fall for 1 of 3 residents (R1) reviewed for post fall care in the sample of 17. The finding include: On 10/9/23 at 11:23 AM, V17 (R1's Niece and Power of Attorney) said R1 fell, and the staff did not assess R1 after the fall. R1's Progress Note dated 9/27/23 showed R1 had an unwitnessed fall and R1 did not know what she was doing prior to the fall. On 10/10/23 at 10:54 AM, V3 (Licensed Practical Nurse- LPN) said she was taking care of R1 when R1 fell. V3 said R1 had an unwitnessed fall. V3 said R1 reported R1 did not hit her head however it was unclear if R1 did because R1 had periods of confusion. V3 said neurological assessments were started. On 10/10/23 at 12:05 PM, V8 (Restorative Nurse) said he oversaw falls at the facility. V8 said if a resident had an unwitnessed fall neurological assessments are done. V8 said R1 should of had neurological assessments done because the fall was unwitnessed, and it was not clear if R1 hit her head. V8 looked at a Neurological Evaluation…

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 comfortable water temperatures for 8 of 8 residents (R1, R2, R3, R4, R5, R6, R7, R8) reviewed for water temperatures in the sample of 15. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include bilateral primary osteoarthritis of the knee, mild protein calorie malnutrition, wedge compression fracture of the 4th lumbar vertebra, hypertension, atherosclerotic heart disease, and late onset Alzheimer's dementia. R1's facility assessment dated [DATE] showed she has severe cognitive impairment and is dependent on staff for bathing and requires extensive assistance of staff for all other cares. R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include unspecified convulsion, dementia with behavioral disturbance, osteoarthritis, major depressive disorder, hypertension, and hypokalemia. R2's facility assessment dated [DATE] showed she has severe…

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 dispose of expired medications. This failure has the potential to affect all residents in the facility. The findings include: On 6/7/23 at 9:35AM, V18 (Registered Nurse) stated, We should be keeping track of the expiration dates for medications as much as we can and discarding them as soon as they are expired. Medications that are expired have the potential to lose their efficacy over time. On 6/7/23 at 1:31PM, a review of the third floor medication cart showed: a bottle of Atropine belonging to a discharged resident that expired 4/11/23, Saccharomyces Boulardii Probiotic expired 02/23, Tums expired 12/22, Fish Oil expired 2/23, Acidophilus expired 06/22, and B-complex expired 02/23. On 6/7/23 at 1:52PM, a review of the second floor medication cart and medication storage room showed: nephro vitamin expired 03/23 and 3 bottles of Oscal expired 04/23. On 6/7/23 at 2:15PM, a review of the first floor medication cart showed: nephro vitamin expired 03/23, zinc 50mg expired 04/23, and oyster shell calcium expired…

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 communicate a resident change in condition to the Physician and to other staff in the facility. This facility failure resulted in R70 being fed a meal when he could not safely swallow the food. This applies to one of one resident (R70) reviewed for notification in the sample of 23. The findings include: The facility face sheet for R70 shows diagnoses to include acute kidney disease, Bell's palsy, acute respiratory failure, adult failure to thrive and hypertension. R70's Physician Order Sheet shows R70 was under hospice care and was a Do Not Resuscitate. The facility assessment dated [DATE] shows R70 has severe cognitive impairment, requires staff assistance for most activities of daily living, and has complaints of pain and difficulty swallowing. The hospice RN visit note dated 6/5/23 shows collaboration with [V3 (Unit Manager, Licensed Practical Nurse)]. The note shows [V3] telling [V5] (Hospice Nurse) that R70 is not doing well and thinks…

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

Based on observation, interview, and record review, the facility failed to perform surgical wound care in a manner to prevent infection for 1 of 1 resident (R325) reviewed for non-pressure skin care in the sample of 23. The findings include: R325's electronic face sheet printed on 6/8/23 showed R325 has diagnoses including but not limited to severe sepsis with septic shock, colostomy, surgical aftercare, diverticulitis of large intestine with perforation and abscess, and peritonitis. R325's physician's orders dated 5/31/23 showed, Wound vac (vacuum) to abdomen running at 125mmhg .change dressing to abdominal wound vac 3 times weekly, change colostomy bag and appliance one time a day every 7 days. R325's care plan dated 5/31/23 showed, (R325) was admitted with dehisced surgical wound on abdomen (with wound vac), due to perforated bowel. She is at risk for additional alterations in skin integrity related to impaired mobility, impaired nutrition, and surgical wound. R325's care plan dated 6/5/23 showed, The resident has infection of the wound, 5/30/23 Piperacillin Sod- Tazobactam…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform urinary catheter care in a manner to prevent infection for 1 of 5 residents (R88) reviewed for urinary catheters in the sample of 23. The findings include: R88's electronic face sheet printed on 6/8/23 showed R88 has diagnoses including but not limited to congestive heart failure, asthma, type 2 diabetes, encephalopathy, neuromuscular dysfunction of bladder, and edema. R88's facility assessment dated [DATE] showed R88 has no cognitive impairment. R88's physician's orders showed, 8/12/22 Consult urology for chronic dysuria, frequent UTI (urinary tract infection), and chronic colonization of drug resistant organisms in the urine. R88's physician's orders dated 4/25/23 insert Foley catheter for suspected urinary retention, change Foley drainage bag as needed, Foley catheter care every shift and as needed. R88's care plan dated 5/16/22 showed, (R88) requires an indwelling urinary catheter related to diagnosis of neurogenic bladder.…

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 identify a significant weight loss for a resident (R109) receiving dialysis. This applies to 1 of 4 residents reviewed for dialysis in the sample of 23. The findings include: R109's electronic face sheet printed on 6/8/23 showed R109 has diagnoses including but not limited to cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes, systemic sclerosis w/ lung involvement, end stage renal disease, and occlusion and stenosis of bilateral carotid arteries. R109's physician orders dated 5/11/23 showed, Peritoneal dialysis (PD) site care, continue current PD order 9.5hours, 5 fills, 2.5L each (total 12.5L-3 bags of 1.5% yellow) needed with 5.5L wasted per treatment. No last fill. Document cycler information and vitals/weight on flowsheet in (local dialysis center) binder daily. (Local dialysis center) will visit resident every 2 weeks, assess and collect flowsheets. R109's weight record showed on 6/4/23 R109 weighed 175.1 lbs. On 06/8/23, R109 weighed 153 pounds which is a 12.62% weight loss over a 4-day period. R109'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 incontinent care was provided in a manner to prevent cross-contamination for 1 of 8 residents (R45) reviewed for infection control in the sample of 23. The findings include: R45's admission Record, printed by the facility on 6/7/23, showed he had diagnoses including hemiplegia and hemiparesis (paralysis and weakness to one side of the body) following a cerebral infarction (stroke), and polyneuropathy (the malfunction of many peripheral nerves throughout the body). R45's 4/27/23 facility assessment showed he required extensive assist from staff for bed mobility, toileting, personal hygiene and dressing. The assessment showed R45 was frequently incontinent of bowel and bladder. R45's Cognition care plan, with a target date of 7/9/23, showed he had poor self and environmental awareness, difficulty understanding information being provided, and difficulty being able to respond to such communication appropriately. R45's visual function care plan, with a revision date of 3/15/23, showed he had impaired visual…

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.