Rock River Health Care

Based on observation, interview, and record review the facility failed to administer medications as ordered by the physician. There were 30 opportunities with 12 medication errors resulting in a 40% medication error rate. These failures apply to 2 of 3 residents (R23, R47) observed in the medication pass. The findings include:On 12/8/25 at 10:13 AM, V9 Registered Nurse prepared R47's morning medications. V9 dispensed a tablet of chewable aspirin 81mg in R47's medication cup. V9 administered the aspirin to R47.R47's Physician Orders dated 11/26/25 shows and order Aspirin Enteric Coated Tablet Delayed Release 81 mg. Give 1 tablet by mouth in the morning for heart health.On 12/09/2025 at 8:13 AM, V10 Licensed Practical Nurse prepared R23's morning medication including 11 oral tablets. R23 was in her room, in chair, with her breakfast on the overbed table. At 8:23 AM, V10 set R23's medication cup with 11 medications on R23's breakfast tray. At 8:30 AM, V10 administered R23's insulin (R23's medications remained on the breakfast tray). V10 left the room, signed off R23's medications in…

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

Based on observation, interview and record review the facility failed to ensure residents medications were securely stored and inaccessible to residents for 2 of 19 residents (R43, R59) reviewed for medication storage in the sample of 19. The findings include: 1.R43's physician order report printed 12/9/25 showed R43 was prescribed Novolog insulin and Ozempic related to his diagnosis of Type 2 Diabetes Mellitus. The report showed no physician order to allow R43 to keep medications in his room or to allow R43 to self-administer his medications. On 12/8/25 at 10:11 AM, R43 was seated in his bed. On R43's bedside table was a Novolog insulin pen and a pen of Ozempic medication. Both pens had been opened and used, with medication missing from each pen. R43 stated he kept the medications by his bedside because sometimes my meds are given late here so I give them to myself. On 12/9/25 at 8:08 AM, R43's Novolog insulin and Ozempic pens remained on R43's bedside table. On 12/0/25 at 8:09 AM, V2 Director of Nursing stated residents cannot have any medications in their room and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure a resident and their personal property was treated with respect. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 3.The findings include:R1's face sheet shows he is a [AGE] year-old male with diagnoses including COPD, asthma, tobacco use, anxiety, hypertension and schizoaffective disorder.On 8/19/25 at 8:53 AM, R1 was in his room wearing oxygen, a laptop and other personal items were on his bedside table. R1's bedside table located next to his bed including his cigarettes, personal hygiene products and personal mail. R1 said on 8/13/25, he went out to the hospital for shortness of breath. When he came back from the hospital, R2 (R1's roommate) told him female staff went through his belongings and took $40.00 and two jars of hemp. R1 showed this surveyor the text to V1 (Administrator) Your people went through my belongings. I'm calling the police. I'm missing $40.00. R1 said he felt violated and disrespected, 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 maintain a comfortable temperature by not keep a resident's room below 81 degrees Fahrenheit for 1 of 3 residents (R1) reviewed for comfortable homelike environment in the sample of 3.The Findings include:R1's Face Sheet printed on 7/28/25 indicated R1 had the diagnosis of chronic obstructive pulmonary disease.A facility assessment done on 7/24/25 showed R1's mental status was intact. On 7/28/25 at 8:43 AM, R1 said the temperature in his room was too hot and had been uncomfortable for the last few days. R1 had a built-in wall air conditioner in his room. There was no portable air conditioner in R1's room. On 7/28/25 at 8:43 AM, the surveyor used a thermometer that had been calibrated in an ice bath to check R1's room temperature. R1's room temperature was 81.7 degrees Fahrenheit. The air coming out of the wall air conditioner's vent was 81.6 degrees Fahrenheit.On 7/28/25 at 10:26 AM, R1's room temperature was 81.5 degrees Fahrenheit. The air coming out of the wall air conditioner's vent was 81.3 degrees…

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 free from significant medication error. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's face sheet shows he is a [AGE] year-old male with diagnoses including post traumatic seizures, COPD, major depressive disorder, anxiety, and personal history of traumatic brain injury.On 7/21/25 at 8:42 AM, R1 was in his room lying in bed, V5 (Licensed Practical Nurse-LPN) was in his room taking his vitals. At 8:43 AM, the emergency services arrived and entered R1's room. At 8:46 AM, R1 left the building with emergency services.On 7/21/25 at 8:46 AM, V6 (Certified Nursing Assistant-CNA) said R1 is alert and oriented x3, he was fine this morning when he got up and ate breakfast. After breakfast he wanted to lay down and usually, he refuses to lay down and stays up in his wheelchair till after dinner. He transferred R1 back in bed and R1's body started jerking in bed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify a new skin alteration for a resident who is at risk for developing pressure wounds which applies to 1 of 3 residents (R1) reviewed for pressure wounds in a sample of 3. The findings include: R1 facility assessment dated [DATE] showed R1 is a [AGE] year-old cognitive male resident admitted to the facility on [DATE] with diagnoses which include a history of traumatic brain injury, bilateral lower leg amputation, lack of coordination, and unspecified dementia. This assessment showed R1 is dependent or needs maximum assistance with activities of daily living which include transferring, bed mobility, showering/bathing, and getting dressed. On 7/1/25 at 10:30 AM, V2 Director of Nursing performed a skin check on R1. During the skin check, two open areas were identified. One on the right and left lower buttocks. The right open area was measured at 1.2 x 0.5 x 0.1 centimeters (cm). The left buttock open area was measured at 0.75 x 2.0 x…

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 resident's continuous positive airway pressure (CPAP) machines or supplies which applies to 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for respiratory treatments in a sample of 5. The findings include: On 6/4/25 the facility provided a list of residents using CPAP machines in the facility which included R1-R5. 1. R1's Facesheet printed on 6/4/25 showed R1 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included: acute respiratory failure and obstructive sleep apnea. On 6/4/25 at 9:30 AM, R1 was in his room watching television. R1's CPAP machine was sitting on the nightstand next to the bed. R1 stated he has used the same mask, water tank, and tubing (heated coil tubing) for the machine for over a year. R1 stated prior to coming here he would get supplies delivered every 3-6 months depending on what the item was. R1 stated he had lung issues and did not want to get sick. R1 stated he used 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 ensure the accuracy of medication administration records (MAR) for 3 of 3 residents (R1, R2, and R3) reviewed for pharmacy services in the sample of 3. The findings include: 1. R1's MAR printed on 3/5/25 had blank spots for 2/8/25 and 2/9/25 for the following medications: aspirin, budesonide-formoterol fumarate inhaler, cholestyramine, colchicine, flecainide acetate, folic acid, glipizide, furosemide, pregabalin, metoprolol, pantoprazole sodium, apixaban, and hyoscyamine sulfate. On 3/5/25 at 1:10 PM, R1 said to the best of her recollection she did receive her medications on 2/8/25 and 2/9/25. A facility assessment done on 3/4/25 showed R1's mental status was intact. 2. R2's MAR printed on 3/5/25 had blank spots for 2/8/25 and 2/9/25 for the following medications: aripiprazole, atorvastatin, cholecalciferol, clonazepam, donepezil hydrochloride, fenofibrate, fluoxetine, furosemide, Humalog insulin, Lantus insulin, miconazole, polyethylene glycol, montelukast sodium, multivitamin, mirabegron, nystatin powder, olanzapine,…

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

Based on observation, interview, and record review the facility failed to ensure staff followed enhanced barrier precautions by not wearing the required personal protective equipment (PPE) when emptying an indwelling urinary catheter drainage bag for 1 of 2 residents (R1) reviewed for infection control in the sample of 3. The findings include: R1's Order Summary Report printed on 3/5/25 showed R1 was on enhanced barrier precautions because of an indwelling urinary catheter. R1's Care Plan with an initiated date of 6/27/24 showed R1 was at high risk for infection because of a catheter. Listed under interventions was, PPE to be worn during high contact activities: gown, and gloves and shield when risk of splash is present (i.e. emptying a catheter, working with feeding tube, etc.). R1's name appeared on the December 2024 infection control log. The log indicated R1 received an antibiotic for a urinary tract infection. On 3/5/25 at 8:12 AM, on the door of R1's room was a sign indicating R1 was on enhanced barrier precautions. R1 had an indwelling urinary catheter drainage bag hanging on…

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

Based on interview and record review the facility failed to have an RN (Registered Nurse) for 8 hours per day 7 days a week. This applies to all 74 residents residing in the facility. The findings include: The CMS-671 long-term care facility application for Medicare and Medicaid dated October 7, 2024, shows, there are 74 residents residing in the facility. The facility's daily assignment sheet dated April 28, 2024, shows, there was only an RN in the building from 7:00 AM-11:00AM (4 hours and not 8 hours). The facility's daily assignment sheets dated June 2, 2024, and October 6, 2024, shows, there were no RNs working. On October 9, 2024, at 1:30 PM, V2 Director of Nursing (DON) confirmed there were no RNs working 8 hours per day on April 28, June 2 and October 6, 2024. She stated, there should be an RN that works every day for at least 8 hours per day. The facility's Registered Nurse Staffing policy dated January 2024 shows, Policy: The facility shall ensure that a Registered Nurse is available for supervision in the facility . Procedure: 1. The facility must use the services of a…

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

Based on observation, interview and record review the facility failed to follow the recipe and menu for the noon meal. This applies to all 74 residents in the facility. The findings include: The facility's week 1 food menu for the noon meal on October 7, 2024, shows, cheesy chicken baked penne, Italian blend vegetables, mandarin oranges, coffee/tea and condiments. On October 7, 2024, at 10:23 AM, V13 (Cook) was preparing lunch for the residents on puree diets. She had chicken, noodles and broth in a pan on the stovetop. She stated, that was what the puree diet was getting for lunch and proceeded to puree that for them. She also pureed carrots for them. On October 7, 2024, at 11:41 AM, V13 (Cook) was starting to plate the noon meal for all residents. There was a pan of penne pasta in a red sauce and Italian blend vegetables on the steam table. All of the residents on a regular diet were served that. She stated, the pasta had chicken, onion and some cheese in it. She stated, she did the regular diets fresh that was why the pureed diets didn't get the same thing. She just simmered 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 controlled substances were double locked. This applies to 4 of 4 residents (R11, R14, R34, & R62) reviewed for controlled substances in the sample of 20. The findings include: On October 7, 2024, at 10:09 AM, the medication refrigerator in the second floor medication room was opened with the lock sitting on top of the refrigerator. R11, R14, R34 & R62's liquid lorazepam (anti-anxiety/Scheduled IV controlled substance) was in the door of the medication refrigerator. V2 Director of Nursing (DON) stated, the refrigerator should have been locked. R11, R14, R34 & R62's order entries show, an order for lorazepam oral concentrate 2 mg (milligrams)/ml (milliliter). The facility's medication storage in the facility dated February 2024 shows, Policy: Medications and biologicals are stored safety, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer…

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 provide the residents with an appetizing and appealing meal for 8 of 8 (R16, R32, R35, R45, R56, R66, R69, & R72) residents reviewed for appearance, palatability and preferred temperature in the sample of 20. The findings include: On 10/07/24 at 9:41 AM, R56 said, what is cold is warm, what is hot is cold. The food they make is hard to identify. They do not inform you about the food. There are no alternatives. On 10/07/24 at 11:59 AM, R32 said, there is no menu. There is no alternative menu. I'm allergic to pork, in that case they will provide PB&J (peanut butter and jelly). But I have my own food I make. Having a substitution menu sounds like a good Idea, I don't think it will happen here. On 10/07/24 at 12:16 PM, R16 lying in bed on back with head of bed low. R16's roommate was eating lunch. We are not provided a menu for meals. I cannot request substitutions. I have requested mashed potatoes for lunch multiple times, they cannot even bring me that. I don't like meat; I like vegetables. The vegetables are usually so poorly…

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

Based on observation, interview and record review the facility failed to provide residents with available drinks when requested by the resident for 6 of 11 residents (R2, R12, R17, R24, R31, and R27) reviewed for drinks available to meet needs/hydration in the sample of 20. The findings include: On 10/08/24 at 12:30 PM, R2, R12, R17, R24, R31, and R27 requested milk during their noon meal. The facility did not provide them with milk. On 10/08/24 at 12:45 PM, V5 LPN (Licensed Practical Nurse) said, the staff called down for milk and was told by the kitchen that only 5 milks can come up to the floor. They (kitchen staff) told us milk is not for lunch. Milk was handed out to 5 residents, but 6 residents were not given milk. The kitchen tells us it's not for lunch, only dinner. On 10/08/24 at 2:19 PM, V4 (Dietary Manager) said, I give one milk at dinner, a lot of residents want milk. We have plenty of milk, 18 cases of milk. If they want milk they can have it. I don't know why they said that about not sending it to them. On 10/08/2024 V5 (LPN) provided a list showing, R2, R12, R17, R24,…

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 dress a resident in a dignified manner. This applies to 1 of 20 (R2) residents reviewed for dignity in the sample of 20. The findings include: On 10/7/2024 at 10:20 AM, R2 was observed sitting up in his wheelchair near the nursing station with pink and green colored pants on with a plaid or checker pattern on them. On the left inner thigh area there was approximately a 4-5-inch rip in the pants with another rip on the right inner thigh area of about 2 inches. On 10/7/2024 at 10:20 AM, R2 said he was embarrassed about his pants. On 10/7/2024 at 11:35 AM, V7 Certified Nursing Assistant (CNA) said [R2] was given a shower that morning and was put in those pants by facility staff before she came in. V7 said you wouldn't dress your mother or grandmother in ripped clothes. V7 said she wouldn't dress a resident in clothes that are ripped or [NAME]. V7 said [R2] is unable to dress himself, he needs assistance with that. R2's current Care Plan states…

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 clean, clutter free shower, and maintain a resident's room in need of repairs. This applies to 2 of 20 (R48, R39) residents reviewed for clean comfortable homelike environment in the sample of 20. The findings include: 1. On 10/7/2024 at 9:34 AM, R48 said the shower room on the second floor is dirty and cluttered. On 10/7/2024 at 10:02 AM, the second-floor shower room had a towel on the floor, a pink basin on the floor with a towel in it, a razor face down in the corner of the room, a rolled up blue gown on the floor, cracked or peeling caulk along the edges of the shower room, and no drain cover on the drain for the shower on the right. On 10/8/2024 at 11:24 AM, V2 Director of Nursing (DON) said the facility's shower room should be a homelike environment, organized, clutter free, clean, no towels on floor, no old clothing, and no soap scum should be in there. 2. On 10/7/24 at 9:23 AM, R39 was lying in her bed. Her room appeared to be dirty and in need of repairs. The baseboard along the bottom wall…

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

Based on observation, interview and record review the facility failed to provide wound care for R56's stage 4 pressure ulcer on the weekend shift for 1 of 5 residents (R56) reviewed for pressure ulcers in the sample of 20. The findings include: On 10/07/24 at 9:30AM, R56 was lying in bed on his left back side. On 10/07/24 at 9:30 AM, R56 said, I have a wound to my left upper buttocks. The wound nurse comes 5 days a week. If the wound nurse is not here, the dressing is not done. If it falls off over the weekend, the nurse will not change it. On 10/09/24 at 11:21 AM, V2 DON (Director of Nursing) said, wound care is documented in the MAR (Medication Administration Record). The floor nurse performs the dressing change on the weekend. Monday through Friday the wound nurse performs the dressing change. The empty box on the MAR denotes the dressing change was not performed. R56's MAR dated September 2024 shows, Wound Care: Left buttock: wound cleanser, skin prep to peri-wound, silver sulfadiazine, cover with gauze island once daily and as needed if becomes soiled or dislodged. every night…

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 supervise residents to prevent a resident from giving food to another resident on a specialized diet for 1 of 20 residents (R38) reviewed for safety supervision in the sample of 20. The findings include: On 10/7/24 at 9:16 AM, R38 was sitting in the dining area falling asleep and slowly feeding herself a breakfast tray that had pureed food on it. At 9:32 AM, R38 was in the same spot in the dining area, she had a package of [Name Brand] snack cakes with doughnut like consistency and was opening the package and began to eat them. V9 (Licensed Practical Nurse/LPN) was sitting at the nurse's station directly across from where R38 was eating the snack cakes and did not question R38 about them or seem concerned she was eating them. R38 told the surveyor another male resident gave them to her. R38's Physician Order Summary shows an order dated 10/4/24 for her to have a pureed diet. A Nursing Progress note on 9/27/24 at 1:34 PM shows that R38 was having trouble swallowing possibly due to phlegm in her throat and was…

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

Based on observation, interview and record review the facility failed to monitor a resident (R20) while taking their medications and failed to provide and/or document provision of medication to a resident (R33) on the MAR (Medication Reconciliation Record). This applies to 2 of 5 (R20, R33) reviewed for mediations in the sample of 20. The findings include: 1. On 10/8/2024 at 8:09 AM, V5 Licensed Practical Nurse (LPN) was observed passing morning medications to R20. V5 put 400 milligrams (mg) of Magnesium Oxide x1, 25 mg Atenolol x1 tab, and a multivitamin tab in a medication cup for R20. V5 brought R20 his medications in a cup, left them in front of the resident on his meal tray, and left without watching him take the medication. V5 then returned to R20's room with an 81 mg Aspirin tab and put that in his medication cup with the first three pills. R20 had not taken the first 3 medications. V5 walked back out of the room and did not monitor R20 taking his medications. On 10/8/2024 at 8:09 AM, V5 said she leaves his medications with him because he won't take them if you are standing…

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 report and keep a resident's room free of bugs/pest. This applies to 1 of 20 residents (R43) reviewed for pest control in the sample of 20. The findings include: On 10/7/2024 at 12:20PM, R43 observed telling V9 Licensed Practical Nurse (LPN) she had wasps in her room. On 10/7/2024 at 12:22PM, approximately 5 black and red bugs were observed on the interior portion of R43's room window. On 10/8/2024 at 12:03PM, approximately 3 black and red bugs were observed on the interior portion of R43's room window. On 10/9/2024 at 11:19PM, one black and red bug was observed on the interior portion of R43's room window. On 10/8/2024 at 12:07PM, V2 Director of Nursing (DON) said resident's rooms should not have bugs in them. On 10/8/2024 at 2:52PM, V6 Maintenance said he was not made aware of any issues with [R43's] room regarding bugs. V6 said an outside pest control company was on site this morning (10/8/2024) but was not here for R43's room. The facility's Pest Control Policy reviewed 11/2022, states . employees are…

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

Based on interview and record review the facility failed to ensure a resident received their scheduled/routine pain medication and failed to document that medications were given on the Medication Administration Record (MAR) for 2 of 3 residents (R1 and R3) reviewed for pharmacy services in the sample of 3. The findings include: 1. R3's face sheet showed R3 had the diagnosis of pain. On 6/4/24 at 10:30 AM, R3 said he missed one dose of his scheduled pain medication of hydrocodone-acetaminophen. R3's Medication Administration Record (MAR) showed on 5/29/24 that his scheduled bedtime pain medication was not given because it was not available. The facility's Patient Centered (PCC) Pass Times policy showed bedtime medications were to be given between 8:00 PM-11:59 PM. On 5/30/24 at 12:56 PM, V6 (Licensed Practical Nurse-LPN) said she took care of R3 on 5/29/24 from 7:00 PM to 7:00 AM on 5/30/24. V6 said she did not give R3 his scheduled bedtime pain medication on 5/29/24 because she was waiting for the pharmacy to deliver the medication. V6 said she waited for the 1:00 AM pharmacy…

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 reconciled for 4 of 4 residents (R2, R3, R4 and R5) reviewed for pharmacy services in the sample of 17. The findings include: On 5/21/24 at 9:40 AM, inside the medication room on the second floor sitting in a box were 20, 2nd floor residents' individual packages of various medications. The dates on these medications were for 5/12/24 at time to be given listed as BED. V6 (Licensed Practical Nurse/LPN) was inside the medication room with the surveyor and said those medications should have been given on 5/12/24 at bedtime. V6 said she has found medications still inside the cart when she comes on duty the next morning that should have been given the evening prior. An individual packet of medication for R2 was one of the 20 resident medications still inside the medication which was Levetiracetam (seizure prevention medication). R2's Medication Administration Record shows the following medications were not signed off as given on 5/12/24 Depakote 500 Milligrams (MG.) to be given in EVE, Flomax…

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

Based on observation, interview, and record review the facility failed to provide catheter care in a manner to prevent cross contamination. This applies to 1 of 3 residents (R3) reviewed for catheter care in the sample of 6. The findings include: R3's admission Record (Face Sheet) showed an original admission date of 10/28/16 with diagnoses to include enlarged prostate, dementia, and schizoaffective disorder. R3's 2/13/24 Quarterly Minimum Data Set (MDS) showed he had moderate cognitive impairment. The MDS showed he had catheter. On 3/6/24 at 9:49 AM, V6 Certified Nursing Assistant (CNA) began catheter care for R3. V6 gathered his supplies, removed R3's incontinence brief, and soaked a wet washcloth in soapy water. V6 wiped R3's penis, starting at the base and going towards the tip, with a wet washcloth. V6 repeated this process several times. V6 also washed R3's buttocks and applied ointment to R3's perineal area. V6 then laid R3's urine collection bag on the floor. V6 then put a folded blanket on the floor, picked up the collection bag off the floor, and placed it on the folded…

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 fall interventions and fall assessments were updated after a resident experienced a fall for one of three residents (R1) reviewed for falls in the sample of three. The findings include: R1's face sheet printed on 9/19/23 showed diagnoses including but not limited to cerebral palsy, Barrett's Esophagus, cardiomyopathy, depression, anxiety, obesity, and quadriplegia. R1's facility assessment dated [DATE] showed moderate cognitive impairment and requires extensive staff assistance with bed mobility, dressing, toilet use, and personal hygiene. The same assessment showed R1 requires total assistance with transfers. R1's progress note dated 9/13/23 at 3:50 AM, showed: Resident observed on floor next to bed positioned on his back. Resident alert and verbally responsive. Resident states that he woke up and was on the floor. The note showed R1 did not have any outward signs of injury and vitals were within normal limits, but he was complaining of neck…

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 implemented and failed to develop an Enhanced Barrier Precautions Policy and Procedures. The facility's Resident Census and Conditions Report (CMS) dated 9/11/23 show there were 67 residents residing at the facility. This report also shows that there are 2 residents with indwelling catheters and 5 residents with pressure ulcers. None of these residents were placed on Enhanced Barrier Precautions. R59, a resident in this facility with a central intravenous catheter was not placed on Enhanced Barrier Precautions. On 9/11/23 at 12:33 PM, V3 (Infection Control) said the facility has not implemented Enhanced Barrier Precautions. V3 said she does not know anything about this and no one has told me about that. On 9/11/23 at 2 PM V4 (Nurse Consultant) said Enhanced Barrier Precautions are additional precautions for residents aside from the normal precautions already in place. V4 said the facility Enhanced Barrier Precautions program including the Policies and Procedures will be…

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

Based on observation, interview, and record review the facility failed to investigate an alleged allegation of financial abuse for 1 of 17 residents (R50) reviewed for abuse in the sample of 17. The findings include: A progress note dated 7/8/2023 timed at 11:00 AM shows, resident visitor/niece called the facility requesting to speak with resident (R50), when informed that resident was eating at this time, visitor/niece stated she would call resident back later. When this writer informed (R50) that his visitor will be back, R50 stated that he did not want to see her at this time. He stated that he had already gave her 50.00 late last night and 100.00 on Thursday and was not gonna give her any more money. This writer then informed Administrator of the situation. This writer also attempted to call resident 2nd and 3rd emergency contacts to inform them of this lady stating she's related to resident and taking him across the street to the a ATM to withdraw money. On 09/12/23 at 9:43 AM R50 was sitting in his wheelchair by his room. R50 said someone had asked him for money in the past…

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 prescribed treatment orders were in place for residents with pressure ulcers and failed to ensure pressure relieving interventions were in place. This applies to 2 of 6 residents (R17, R45) reviewed for pressure ulcers in the sample of 17. The findings include: 1. R17's Physician Order Sheets show he is a [AGE] year old male with diagnosis including stage 4 pressure ulcer of left buttock, paraplegia, end stage renal disease, dependence of renal dialysis, and neuromuscular dysfunction of the bladder. R17's Wound Physician Progress note dated 9/5/23 documents he has a stage 4 pressure wound of the left ischium measuring 0.4 cm (centimeters) x 0.3 cm x 1.0 cm. Wound progress: not improved. Treatment orders include to cleanse with wound cleanser, xeroform gauze, antibiotic ointment and bordered foam dressing. On 09/10/23 at 1:39 PM, R17 was observed lying in bed. V8 (Certified Nursing Assistant) assisted R17 to his side. An open area…

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 fall interventions for a resident with a history of falls (R16) and failed to ensure safety smoking precautions were in place for a resident (R38). These failures apply to two of seventeen residents reviewed for safety and supervision in the sample of seventeen. Findings include: 1. On 9/12/23 at 10:45 AM, R16 was in his wheelchair on the unit and propelled himself into his room and made several attempts to propel himself toward the bathroom entry way. R16 was removed from his room via wheelchair by the assist of V19 (Certified Nursing Assistant) CNA and taken out to the unit. R16's Face sheet printed on 9/11/23 showed diagnoses to include but not limited to epilepsy, dysphagia, dementia, hypertension, hemiplegia, intellectual disabilities, and cognitive communication deficit. R16's Care plan showed R16 is at risk for falls related to impaired mobility, balance, and decrease safety awareness. R16's Minimum data set (MDS) dated…

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 nutritional supplements were provided to residents with significant weight loss and failed to ensure a nutritional assessment was performed for a resident who was re-admitted to the facility with multiple wounds and history of significant weight loss. This applies to 2 of 17 residents (R46, R62) reviewed for weight loss in the sample of 17. The findings include: 1. R46's Physician Order Sheets (P.O.S.) shows he is a [AGE] year old male with diagnoses including unspecified dementia, schizophrenia, anxiety and hypertension. The P.O.S. shows orders for ice cream in the afternoon and evening. R46's Dietary Progress note dated 9/9/23 documents R46's current weight is 140 lb (pounds) he triggered for significant weight loss at three months at 8.1 % (12.4 pound weight loss) and six months at 16.4% (16.4 pound weight loss). Regular diet with milk at all meals and ice cream twice a day and med pass (nutritional shake) three times a day. On…

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

Based on observation, interview, and record review the facility failed to ensure insulin pens were labeled and dated when opened. This applies to 2 of 4 residents (R40, R44) reviewed for medication labeling in the sample of 17. The findings include: 1. On 9/10/23 at 4:47 PM, V6 (Licensed Practical Nurse) administered R40's insulin. R40's Apidra pen (rapid acting insulin) was not dated or labeled. V6 confirmed R40's insulin pen was not labeled and dated and said Insulin pens should be dated when opened and are good for 29 days. R40's Physician Orders dated September 2023 shows orders for Apidra Subcutaneous solution Pen-Injector inject per sliding scale. 2. On 9/10/23 at 4:55 PM, the first floor medication cart was checked. R44's Lantus pen (long acting insulin) was not labeled or dated. R44's Physician Order Sheets dated thru September 2023 shows order for Lantus inject 8 units subcutaneously in the morning. On 09/13/23 at 8:34 AM, V2 (Director of Nursing) said Insulin pens are usually good for 28 dates after opening and should be dated. The facility's undated Medication Storage 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 interview and record review, the facility failed to offer pneumococcal vaccination series per CDC guidelines for 2 of 5 residents (R14, R38) reviewed for immunizations in the sample of 17 The findings include: R14's ([AGE] years old (y/o)) immunization record showed R14 had received pneumovax dose 1 on 11/2/21 but did not specify what kind of pneumonia vaccination R14 received. R38's (72 y/o) immunization record showed R38 had received pneumonia dose 1 on 11/3/2021 but did not specify what kind of pneumonia vaccination R38 received. On 9/12/23 at 9:30 AM-V3 (Infection Control Nurse) handed this surveyor a handwritten note that dose 1 was prevnar 23 (PPSV23). V3 said there was no follow thru or additional series of pneumonia vaccine that has been offered to these residents. V3 said Pneumonia vaccination is important since long term care residents are in a communal living. Pneumonia shot will protect them against lung infections. The CDC (Centers for Disease Control and Prevention) guidelines dated…

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.