Alpine Care of St. Charles LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and assist residents in obtaining routine dental services.This applies to 2 of 3 residents (R57 and R58) reviewed for dental services in a sample of 23.Findings include:1. On 9/23/2025 at 9:50 AM, R58 said he and his wife (R57) had been residing at the facility for a long time and had not seen a dentist. R58 said they both needed routine dental care services. R58 had upper and lower missing and broken teeth, with visible decay. On 9/24/2025 at 4:00 PM, V4 (Social Services Director/SSD) said the facility provided in-house dental services for all residents identified with dental care needs. V4 said social services was responsible for following up with residents who also requested in-house dental services. V4 said the dental company provided monthly services at the facility, and they assisted residents in enrolling in their dental service program.R58's MDS (Minimum Data Set) dated 7/07/2025 showed an admission date of 10/21/2024. The MDS said R58…

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 and monitor residents' personal refrigerators.This applies to 3 of 3 residents (R6, R40 and R74) reviewed for personal refrigerators in a sample of 23.Findings include: 1.On 09/23/2025 at 10:20 AM, the freezer section of R40's personal refrigerator was completed filled with accumulate ice built up over the freezer door. The freezer door was frozen closed and could not be opened. The freezer log for R40's personal refrigerator had not been done on September 8th, 9th, or 10th 2025. 2.On 09/23/2025 at 10:32 AM, R6's personal refrigerator contained a 1lb (pound) 3oz (ounce) bottle of strawberry fruit spread that expired June 2023. Half of the freezer section was built up with ice. The refrigerator had a melted cup of strawberry ice cream, and the bottom of the refrigerator was dirty with un-identifiable crumbs. The refrigerator temperature log had not been completed September 5th -10th, 2025 and September 20th -22nd, 2025. 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 perform hand hygiene and change gloves when rendering care, and ensure urinary drainage bags were kept off the floor.This applies to 3 of 3 residents (R44, R58, and R63) reviewed for infection control in a sample of 23.Findings include:1. On 9/23/2025 at 9:50 AM, R58 was in bed, and his full urinary catheter drainage bag was directly on the floor. Then V8 (Certified Nurse Assistant/CNA) entered the room and said she was going to assist R58 with his routine morning care. V8 donned PPE (Personal Protective Equipment), including gloves. V8 applied a new incontinence brief to R58 and assisted R58 with putting on his pants. V8 put R58's catheter tubing and bag inside his pant leg and then placed the bag directly on the floor. V8 proceeded to place R58's soiled clothing in the soiled bin and then put R58's slippers on him. V8 assisted R58 into his wheelchair and then combed his hair. V8 did not change her gloves in between R58's different care activities. 2. On 9/23/2025 at 10:35 AM, R44 was in bed. V8 and V10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to investigate allegations of sexual abuse in a timely manner. The facility also failed to implement their Abuse policy and procedure and conduct a comprehensive investigation of the alleged sexual abuse and report the abuse to the state health department and police department. This applies to 1 of 5 residents (R5) reviewed for sexual abuse in a sample of 12. The findings include: The EMR (Electronic Medical Record) shows that R5, a [AGE] year-old with diagnoses of dementia in Alzheimer's disease, major depressive chronic pain, difficulty in walking, cognitive communication deficit, depressive disorder, autoimmune thyroiditis, osteoporosis, Lyme disease, hypothyroidism, anxiety disorder, hypertension, and spinal stenosis. R1 was admitted to the facility on [DATE]. R5's MDS (Minimum Data Set) dated 8/5/2024, showed R1 had moderate cognitive impairment. The progress notes dated 8/16/2024 showed that R5 was sent to the hospital related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure radiological services were provided timely, and to meet the needs of the residents' with a change in medical condition. This applies to 1 of 3 residents (R1) reviewed for injury of unknown origin. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 was sent to the hospital on 8/16/2024 due to acute comminuted fracture of right proximal tibia and fibula. R1's diagnoses included ESRD (End Stage Renal Disease, dependent on dialysis, anemia, atherosclerotic heart disease, congestive heart failure, chronic pain, dementia, diabetes mellitus. R1's MDS (Minimum Data Set) dated 6/11/2024, shows R1 had severe cognitive impairment, and required extensive assistance with bed mobility, hygiene, and uses mechanical transfer lift device for transfers to recline wheelchair during dialysis days. R1 goes to dialysis 3 times a week. R1 goes to the facility's dialysis unit in his reclining…

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 and date medications after opening to determine expiration dates. In addition, facility also failed to discard a narcotic medication that has a broken seal. This applies to 6 of 6 residents (R16, R22, R25, R44, R88, R445) reviewed for labeling, storage, and expiration of drugs in the sample of 18. The findings include: On July 23, 2024, at 3:40 PM, the 600-hallway cart was monitored with V14 LPN (Licensed Practical Nurse), and the following was observed: 1. R16 has two Wixela inhalers (Fluticasone Propionate and Salmeterol Inhalation Powder) which were opened and not dated. The pharmacy's recommended expiration date showed to discard 30 days after opening the foil pouch. 2. R25's Humalog Kwik Pen was opened and not dated. The pharmacy's recommended expiration date showed to discard 28 days after it was opened. 3. R22's Basaglar Kwik Pen was opened and not dated. The pharmacy's recommended expiration date shows to discard 28 days after it was opened. 4. R445's Tobramycin 0.3% and Dexamethasone 0.1%…

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 menu spreadsheet to provide the portion serving size of pureed beef top round roast beef. This applies to 5 of 5 residents (R6, R20, R38, R42, R75) reviewed for pureed diets in the sample of 18. The findings include: Facility Spring/Summer Menu for week 2 Monday included to use #6 scoop for pureed beef top round roast beef. On July 22, 2024 at 12:07 PM, the lunch meal service was observed in the facility kitchen with V6 (Cook) and V7 (Dietary Aide) on the tray line. V6 and V7 used #8 scoop to serve the pureed beef top round roast and R6, R20, R38, R42 and R75 received the same. R6, R20, R38, R42 and R75's meal tickets also showed a serving size of #6 scoop of pureed beef top round roast. On July 22, 2024 at 12:23 PM, when V5 (Dietary Director) was shown the menu spreadsheets, V5 stated that the facility should have followed the serving size as shown on the meal ticket for the item served. On July 22, 2024 at 12:26 PM, (Registered Dietitian) stated that the dietary staff should have followed the menu…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to request a re-evaluation for a PASARR II (Pre-admission Screening and Resident Review) screening for a resident with a SMI (serious mental illness) diagnosis within the required timeframe. This applies to 1 of 1 residents (R59) reviewed for PASARR in the sample of 18. R59's EMR (Electronic Medical Record) showed R59 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, specified anxiety disorder, and PTSD (Post-Traumatic Stress Disorder). R59's MDS (Minimum Data Set) dated May 24, 2024 showed R59 was cognitively intact. R59's care plan dated February 23, 2023, showed R59 presents with a troubled past secondary to bipolar disorder and diagnoses of PTSD and anxiety. Interventions included conduct the appropriate assessments to promote knowledge and understanding of R59's past, remind and encourage R59 to verbalize her thoughts and feelings during her 1:1 session with the visiting psychotherapist. On July 22, 2024 at 3:04…

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 assist a resident that was assessed to require assistance with ADLs (Activities of Daily Living). This applies to 3 of 4 residents (R76, R79, R86) reviewed for activities of daily living in the sample of 18. The findings include: 1. R79's EMR (Electronic Medical Record) showed R79 was admitted to the facility on [DATE], with diagnoses that included hydrocephalus, major depression, unspecified psychosis, anxiety, cognitive communicative deficit, unspecified focal traumatic brain injury with loss of consciousness, and traumatic hemorrhage of cerebrum. R79's MDS (Minimum Data Set) dated April 19, 2024, showed R79 had severe cognitive impairment and required substantial/maximal assistance for toileting, showering, and personal hygiene. R79's care plan showed R79 is incontinent of bowel and bladder and requires assistance with perineal care and interventions include checking R79 for incontinence episodes and anticipate his toileting needs…

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 assess and provide appropriate splints and therapy services to maintain and/or prevent further progression of deformities or reduction in range of motion. This applies to 1 of 3 residents (R76) reviewed for range of motion in the sample of 18. The findings include: R76's EMR (Electronic Medical Record) showed R76 was originally admitted to the facility on [DATE]. R76 was sent to the hospital on July 12, 2024, and returned to the facility on July 14, 2024. R76's diagnosis included quadriplegia, major depressive disorder, morbid obesity due to excessive calorie intake, and critical illness myopathy. R76's MDS (Minimum Data Set) dated May 28, 2024, showed R76 was cognitively intact and was dependent on staff for all ADLs (Activities of Daily Living). R76's restorative care plan-initiated September 28, 2023, showed R76 required assistance with applying left resting hand splint during the day while patient is out of bed and removed prior to…

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

Based on observation, interview and record review, the facility failed to ensure that there was enough oxygen in the resident's portable oxygen tank, to promote delivery of oxygen as ordered by the physician. This applies to 1 of 1 resident (R3) reviewed for oxygen therapy in the sample of 18. The findings include: R3 had multiple diagnoses including metabolic encephalopathy, hemiplegia affecting right dominant side, chronic respiratory failure with hypoxia and dependence on supplemental oxygen, based on the face sheet. On July 23, 2024 at 2:10 PM, R3 was sitting in her wheelchair inside the unit dining room attending the resident group meeting. R3 was observed with on and off coughing and was not participating with the group discussion. R3 had an oxygen nasal cannula in place attached to a portable oxygen (E tank) located at the back of the resident's wheelchair. The gauge of the said portable oxygen was observed at the red area with a mark refill. A facility nurse was immediately called by the State Agency personnel to inform of R3's condition and the need for the portable oxygen…

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 according to physician's order. There were 25 medication opportunities with 3 errors, resulting in a 12% medication error rate. This applies to 2 of 7 residents (R37, R52) reviewed for medication administration in the sample of 18. The findings include: 1. R37's Medication Administration Record (MAR) showed that R37 was prescribed multiple medications which include Heparin Sodium Injection 5,000 units per milliliter (ml). The physician's order showed to inject 1 ml (5,000 units) of Heparin subcutaneously every 8 hours for anticoagulation. On July 23, 2024, at 1:57 PM, V9 (Registered Nurse/RN) prepared to administer Heparin Sodium to R37. V9 drew 0.9 ml (4,500 units) from the Heparin vial. As V9 was about to administer the medication, the dose was verified and when checked, 0.1 ml was still left in the vial. V9 then proceeded to aspirate the remaining Heparin from the vial, to administer a total of 5000 units. 2. R52's MAR shows multiple medications which include Docusate Sodium 100 mg…

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 standards of infection control practices with regards to hand hygiene and gloving during provisions of incontinence care. This applies to 1 of 5 residents (R13) reviewed for infection control during provisions of care in the sample of 18. The findings include: On July 24, 2024, at 10:26 AM, V17 and V18 (Both Certified Nursing Assistant/CNA) rendered incontinence care to R13 who was heavily wet with urine and had a large bowel movement. V17 used wet wipes to clean R13 from front to back. After she cleaned the front perineum, she removed her gloves and washed her hands, then she continued to clean the back perineum. Due to the large amount of fecal matter, V17 changed her gloves twice without hand hygiene and continued to wipe R13's buttocks. After she completed wiping the back perineum, V17 applied barrier cream and incontinence brief while wearing the same soiled gloves. On July 24, 2024, at 2:35 PM, V2 (Director of Nursing/DON) stated that during incontinence care, the staff must perform hand hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy to notify the physician and POA (Power of Attorney) for change in residents' condition. This applies to 1 of 5 residents (R1) reviewed for delay in notification in resident's condition. The findings include: The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE]. R1, a [AGE] year-old with multiple diagnoses included epileptic seizure, vascular dementia, aphasia due to cerebral infarction, post traumatic head injury, major depressive disorder, anxiety, bipolar disorder and SAD (schizoaffective disorder). The nurse's progress note dated 3/6/2024 showed R1 had a seizure on 3/6/2024 before breakfast had lasted 1.5 to 2 minutes. The notes showed R1 was monitored, and POA and physician were notified. The notes showed POA insisted R1 be sent to the hospital. R1 left the facility via 911 at 12:30 P.M. R1 was stable and had returned to the facility at 4:30 P.M. On 3/15/2024 at 1:45 P.M., V3 (RN) said on 3/6/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide residents toileting assistance and assistance with weekly showers per facility policy. This applies to 6 of 6 residents (R2, R3, R4, R5, R8, R11) reviewed for ADL (Activities of Daily Living) assistance in a sample of 13. The findings include: 1. MDS (Minimum Data Set), dated 10/5/23, shows R5 was cognitively intact, R5 was dependent on staff for showers/baths and toileting hygiene, and R5 required substantial/maximal assistance for personal hygiene. Incontinence Care Plan, initiated 6/20/22, shows R5 was incontinent of bladder. Ileostomy/Colostomy care plan, initiated 8/4/20, shows R5 had altered bowel functioning due to the presence of an ileostomy and staff were to provide ileostomy/colostomy care every shift and as needed including maintaining the ostomy site, keeping it clean and dry. ADL Care Plan, initiated 9/1/23, shows R5 required extensive assistance for toileting. On 12/7/23 at 11:41 PM, R5 stated he had a colostomy and he becomes…

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 staff had reported immediately an allegation of sexual abuse. This applies to 1 of 2 (R1) residents reviewed for abuse in the sample of 5. The findings include: The EMR (Electronic Medical Record) showed R1, a [AGE] year old female with diagnoses included but not limited to unilateral primary osteoarthritis of right hip, COPD (chronic obstructive pulmonary disease), UTI (urinary tract infection), lack of coordination, pain to the right and left arm, CKD (chronic kidney disease), dysphonia, atrial fibrillation, CHF (congestive heart failure), anxiety disorder, major depressive disorder, bariatric surgery status, morbid obesity, nicotine and opioid dependence. R1 was admitted originally admitted to the facility on [DATE] and was readmitted on [DATE]. The Minimum Data Set (MDS) dated [DATE] showed R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 14 out 15. The MDS showed R1 required extensive to total…

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 food was prepared and served in a manner to prevent cross-contamination and food-borne illness. The facility also failed to ensure the chemical sanitation level testing for the chemical dishwasher was performed and documented. These failures have the potential to affect all the residents in the facility. The findings include: The Resident Census and Conditions of Residents, CMS 672 form, dated 9/28/23 showed 79 residents resided in the facility. On 9/28/23 at 12:15 PM, V2 (Director of Nursing) said there are 2 residents in the facility who have feeding tubes/g-tubes. V2 said both residents receive food by mouth. On 9/26/23 at 9:10 AM, V19 (Dietary Manager-DM) said the lunch menu for the day was ham, steamed cabbage, and seasoned potato wedges. V19 said chicken, beef, BLTs, and other sandwiches are the substitutes available for residents that do not want the ham. At 9:35 AM, V22 (Dietary Aide) tested the chemical sanitation level for the chemical dishwasher. V22 said the testing should be done during…

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 employee treated a resident in a dignified manner for 1 of 1 residents (R83) reviewed for resident rights in the sample of 18. The findings include: On 9/28/23 at 9:00 AM, R83 was in her room, sitting her reclined wheel chair. R83 stated, On Tuesday night a tall, thin, colored man came in my room, sat over in that green chair and used his cell phone for a while. He barely talked to me at all. When I said something to him, he told me that I talked too much and went back to his cell phone. He's a CNA (Certified Nursing Assistant). I've only seen him here a few times and I don't think I've seen him since then. I know he was hiding from the other staff. He was trying to get out of work. It happened after supper, but before 10 PM. I know because he was off work at 10 PM. I didn't like him in here like that. R83's Face Sheet dated 9/28/23 showed diagnoses to include, but not limited to: quadriplegia, morbid obesity, depression, anxiety, critical…

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 offer and provide activities of daily living (ADL) care for a dependent resident (R17), and failed to provide showers for a resident (R395). These failures apply to 2 of 3 residents reviewed for ADL care in the sample of 18. The findings include: 1) R17's electronic face sheet printed on 9/28/23 showed R17 has diagnoses including but not limited to unilateral post-traumatic osteoarthritis right hip, generalized anxiety disorder, schizophrenia, major depressive disorder, and history of falls. R17's facility assessment dated [DATE] showed R17 has moderate cognitive impairment and requires 1 staff assist for personal hygiene. R17's care plan dated 12/8/21 showed, (R17) has an ADL self-care performance deficit related to impaired ability with dressing and grooming such as: putting on or taking off clothing .unable to groom self satisfactorily, unable to complete task with personal hygiene, unable to bathe and groom self independently related…

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 obtain accurate weights as ordered by the doctor for residents at high risk for nutritional decline for 2 of 3 residents (R23, R75) reviewed for weights in the sample of 18. The findings include: 1. On 9/26/23 at 12:13 PM, R23 was sitting up in her wheelchair, visiting with her husband. R23 said she still had a feeding tube but was trying food now. R23's husband said the plan was to leave the tube in to make sure she was able to eat okay and take her medications. R23's husband said prior to admission to the facility, she was receiving her feeding and medications through the feeding tube. R23's Facesheet dated 9/28/23 showed she was admitted [DATE] and had diagnoses to include, but not limited to: traumatic subdural hemorrhage, diabetes, dementia, anxiety, gastrostomy tube, lack of coordination, feeding difficulties, epilepsy, and morbid obesity. R23's Physician Order Sheet (POS) dated 9/28/23 showed orders for a consistent carbohydrate…

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 pressure injury prevention interventions were in place for a resident with a history of pressure injuries. This applies to 1 of 5 (R40) residents reviewed for pressure injuries in the sample of 18. The findings include: R40's admission Record (Face Sheet) showed an original admission date of 7/2/22 with diagnoses to include paraplegia (paralyzed from chest down), lack of coordination, and borderline personality disorder. R40's 7/8/23 Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status score of 15 out of 15. R40's MDS showed she required extensive assistance of two people for bed mobility, and she was totally dependent upon two staff for transfers. On 9/26/23 at 1:00 PM, R40 was in bed and her heels were in direct contact with her mattress. R40 was in a private room; at the foot of her bed, in a bin, was a pair of off-loading heel protectors. On 9/27/23 at 10:47 AM, V6 and V7 Certified Nursing Assistants (CNAs) entered R40's room to provide perineal and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to apply an arm splint, enter an order for a splint, and initiate a restorative program for R83's arm splint for 1 of 2 residents (R83) reviewed for limited range of motion in the sample of 18. The findings include: On 9/26/23 at 9:46 AM, R83 was sitting in a reclining wheelchair in the common area across from the nurses' station. R83's left arm was resting in her lap, on top of her blankets. R83 was not using her left arm. R83's fingers were curled up toward the palm of her hand. R83 did not have a left arm splint in place. At 12:43 PM, R83 was in the dining room during the noon meal. V4 (LPN - Licensed Practical Nurse) was feeding R83 lunch. R83's left arm resting in her lap. R83 was able to make movements with her right arm but was not moving her left arm. There was no left arm splint in place. On 9/27/23 at 10:18 AM, R83 was sitting in the TV area with a blue splint on her left arm. The splint extended from below her left below to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall prevention measures were in place for a resident (R17), failed to supervise a resident (R17) on aspiration precautions during meal times, and failed to transfer a resident (R395) with a gait belt. These failures apply to 2 of 11 residents reviewed for safety in the sample of 18. The findings include: 1) R17's electronic face sheet printed on 9/28/23 showed R17 has diagnoses including but not limited to unilateral post-traumatic osteoarthritis right hip, generalized anxiety disorder, schizophrenia, major depressive disorder, and history of falls. R17's facility assessment dated [DATE] showed R17 has moderate cognitive impairment. R17's fall risk assessment dated [DATE] showed R17 is a high fall risk. R17's physician's orders dated 5/11/23 showed, Regular diet, finger foods, think liquids, pleasure feed as tolerated, aspiration precautions. R17's care plan dated 3/10/21 showed, (R17) is at a high risk for falls related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide catheter care in a manner to prevent infections for 1 of 2 residents (R395) reviewed for urinary catheters in the sample of 18. The findings include: R395's electronic face sheet printed on 9/28/23 showed R395 has diagnoses including but not limited to malignant neoplasm of prostate, Parkinson's disease, unspecified urethral stricture, schizoaffective disorder, and generalized anxiety disorder. R395's facility assessment dated [DATE] showed R395 has no cognitive impairment, utilizes an indwelling catheter and requires 1 staff assist with personal hygiene. R395's care plan dated 9/18/23 showed, (R395) has an indwelling Foley catheter due to acute urethral stricture. On 9/27/23 at 9:43AM, V10 (Certified Nursing Assistant) provided catheter care and perineal care to R395. V10 stated catheter care is done every time they check and change residents. R395's catheter tubing was not secured and had blood-tinged urine in the tubing. V10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to wear personal protective equipment per their policy for 2 residents (R17, R395) on enhanced barrier precautions, failed to disinfect an insulin pen prior to needle application and insulin administration for a resident (R53). These failures apply to 3 of 3 residents reviewed for infection control in the sample of 18. The findings include: 1. R17's electronic face sheet printed on 9/28/23 showed R17 has diagnoses including but not limited to unilateral post-traumatic osteoarthritis right hip, generalized anxiety disorder, schizophrenia, major depressive disorder, and history of falls. R17's care plan dated 5/17/23 showed, Resident is on enhanced barrier precaution due to wound management .ensure that gown and gloves are used during high-contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting. Device care or use for those with central line,…

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.