Accolade Healthcare Of Savoy

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 193 residents residing in the facility.Findings include:On 3/1/26 at 8:09am, V4 [NAME] stated V3 is the Dietary Manager.On 3/1/26 at 10:55am, V3 Dietary Manager was actively supervising dietary operations in the facility kitchen during resident meal preparations. V3 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Facility assessment dated [DATE] documents the facility's Staffing Plan includes a Certified Dietary Manager. The Facility Staff Roster (undated) documents V3 as the Dietary Manager.The facility Long-Term Care Facility Application for Medicare and Medicaid dated 3/1/26 documents 193 residents reside in the facility.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to develop a water management plan that included the required risk assessment, ranges for control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 193 residents in the facility. B. Based on observation, interview, and record review the facility failed to maintain appropriate handwashing during incontinent care for one of four residents (R92) reviewed for infection control in a sample of 62.Findings include: A. On 3/5/2026 at 11:40AM, the facility water management plan (February 2020) failed to document the required facility water system risk assessment where Legionella and other pathogens could grown and spread in the facility water system. The same record did not document the required consideration of the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) standard or the (CDC) Centers 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.

Failures at this level required more than one deficient practice statement.A. Based on observation, interview, and record review the facility failed to maintain call lights accessible for resident use. This failure affects five of five residents (R1, R2, R11, R64, R97) reviewed for call lights on the sample list of 62.B. Based on observation, interview, and record review, the facility failed to ensure an electric bed remained consistently functional to maintain a resident's toileting independence. This failure affects one resident (R155) of ten reviewed for accommodation of needs in the sample list of 62. Findings Include: A. The facility's Call Lights policy dated January 2026 documents when a resident is in bed or in a chair, staff are to ensure the call light is within easy reach of the resident. On 3/1/26 between the hours of 11:00 AM and 12:00 PM R1, R2, R11, R64, and R97 were observed in their rooms without accessibility to their call light. Call lights were found on the floor or in areas not accessible to the residents. 1. On 3/1/26 at 11:42 AM R1 was in her room in her…

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 adequate supervision and implement interventions to prevent accidents. These failures affect three of eight residents (R124, R133, R148) reviewed for accidents and supervision on the sample list of 62. Findings Include: 1. R133's Medical Diagnoses Sheet date March 2026 documents R133 is diagnosed with Dysphagia, Hemiplegia, and Vascular Dementia. R133's Physician Order Sheet dated March 2026 documents a regular mechanical soft diet order. R133's Minimum Data Set, dated [DATE] documents R133 is cognitively intact and coughs or chokes during meals or when swallowing medications and has complaints of difficulty or pain with swallowing. R133's Care Plan dated 2/27/26 documents R133 has a swallowing problem related to a diagnosis of Dysphagia. R133 is at risk for Choking and Aspiration. R133 should eat only with supervision. R133's Nurse Progress note dated 2/6/26 documents R133 reported she had a choking episode that day during 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 administer medications according to physician's orders for three of 11 residents (R51, R116 and R187) reviewed for medication administration on the sample of 62 residents. The facility had three errors out of 27 opportunities resulting in a medication error rate of 10.71 percent. Findings include: 1.) R51's March 2026 Physician Order Sheet (POS) documents an order for Lidocaine External Patch 4 % (Lidocaine). Apply to left lower back topically one time a day for back pain ON for 12 hours and then remove/OFF for 12 hours and remove per schedule. On 3/2/26 at 5:33 AM V23, Registered Nurse (RN) prepared to apply R51's Lidocaine patch on R51's left lower back. At that time R51 had a lidocaine 4% patch on his back. V23 removed the old patch and placed a new patch on R51's left lower back area. V23 stated at 5:40 AM on 3/2/26 The nurse working must have forgotten to take the old patch off last night. 2.) R116's March 2026 POS documents an order for Calcium Carbonate-Vit D-Min Oral Tablet 600-400 MG-UNIT (Calcium…

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 dated when opened and medications were discarded when discontinued. This failure affects four of four residents (R222, R47, R21, R89) reviewed for medication storage in the sample of 62.Findings include:On 3/4/26 at 11:45 AM the East Medication Cart on first floor contained a Lantus SoloStar Subcutaneous Solution Insulin Pen-injector 100 Unit/ML (Insulin Glargine) for R222 which was undated. V26, RN (Registered Nurse) stated at 11:50 AM on 3/4/26, I did not realize it was not dated. On 3/4/26 at 12:15 pm the Second Floor East Hall medication cart contained the following Insulin pens which were undated:R47's, Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Degludec) was present in the medication cart, and the label did not document an opened date. R47's Medical Record documents this medication was discontinued on 2/23/26. R21's, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) was present in the medication cart, and the label…

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 provide timely and dignified quality of care. This failure affects two of three residents (R1, R155) reviewed for dignity on the sample list of 62.Findings Include: The facility's Resident Rights for People in Long Term Care policy dated November 2018 documents residents in long term care facilities have the right to be treated with dignity and respect. The facility must provide services to keep each resident's physical and mental health at their highest practical levels. 1. On 3/1/26 at 11:42 AM R1 was in her room in her wheelchair. The room smelled of feces and R1 stated she was soiled and needed to be changed. R1 stated she had been waiting a long time for staff to come and change her. R1 appeared upset and kept repeating that she just needed help and wanted to be cleaned up. When asked how she felt, R1 replied, yucky. R1's Medical Diagnoses list dated March 2026 documents R1 is diagnosed with Legal Blindness, Moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was completed upon discharge from the facility for one (R105) of four residents reviewed for resident assessments on the sample list of 62.Findings include:R105's Electronic Medical Record (EMR) documents R105 discharged from the facility to the hospital on [DATE] and did not return to the facility.R105's Census List documents and confirms R105 was discharged from the facility on 11/12/25.R105's MDS summary page (dated 3/3/26) documents R105's last MDS was completed on 10/11/25 and documents R105's Discharge ARD (Assessment Reference Date) of 11/12/25 and was 97 days overdue.On 3/3/26 at 1:09pm, V8 MDS Coordinator confirmed via email that R105 went to the hospital on [DATE] and did not return to the facility. This same email documents a discharge MDS was not completed (for R105) and therefore not done.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and revise a resident's care plan for suprapubic catheter care. This failure affects one (R27) of 35 residents reviewed for care plans on the sample list of 62.Findings include:The facility's Care Planning Policy (revised June 2024) documents the following: To utilize the results of the comprehensive assessment to develop, revise and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consonant with the physician's plan of care. The resident care plan must be kept current at all timesOn 3/1/26 R27 was observed with a suprapubic…

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

Based on interview and record review, the facility failed to provide timely assistance for incontinence cares for one resident (R106) of five reviewed for Activities of Daily Living (ADLs) in the sample list of 62 residents. Findings include:R106's Medical Diagnosis sheet (3/5/2026) documents the diagnosis of Overactive Bladder. R106's Resident Assessment (1/25/2026) documents R106 is cognitively intact. The same assessment documents R106 is always incontinent of bladder and bowel and is completely dependent on staff assistance for toileting hygiene. R106's Care Plan (2/5/2026) documents facility staff will provide incontinence care for R106 as needed. The same record documents R106 is at risk for moisture associated skin breakdown due to incontinence.On 3/2/2026 at 9:15AM, R106 reported using incontinence briefs and being incontinent of both bowel and bladder. R106 reported being dependent on staff to have a wet and/or soiled incontinence brief changed and staff are not responding timely to call lights to change R106's brief. R106 reported waiting up to several hours to be changed…

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 hydration to one of two residents (R133) reviewed for hydration on the sample list of 62. Findings Include: The Hydration and Prevention of Dehydration policy dated January 2026 documents the facility will provide adequate hydration. Nurse Aides will provide and encourage intake of bedside and meal fluids on a daily basis. R133's Medical Diagnoses Sheet dated March 2026 documents R133 is diagnosed with Dysphagia, Diabetes, Chronic Kidney Disease Stage Four and Vascular Dementia. R133's Dehydration Risk dated 2/21/26 documents R133 is at risk related to Dementia, Diabetes, Antipsychotic Medications, and Incontinence. R133's Minimum Data Set, dated [DATE] documents R133 is cognitively intact and coughs or chokes during meals or when swallowing medications and has complaints of difficulty or pain with swallowing. R133's Care Plan dated 2/27/26 documents R133 has a swallowing problem related to a diagnosis of Dysphagia. R133 is also at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer and administer an influenza vaccine to ensure a resident was up to date for vaccines for one (R11) of five residents reviewed for immunizations on the sample list of 62.Findings include:R11's Face Sheet dated 3/5/26 documents R11 was admitted to the facility on [DATE], is [AGE] years old and has Type 2 Diabetes Mellitus.R11's Immunization tab documents R11 last received an influenza vaccine on 10/20/23.R11's Vaccine Consent forms dated 5/2/25 documents R11 consented to receive an annual influenza vaccine. These same records document verbal consent obtained on 5/2/25 and further documents resident combative during the time of vaccine and resident refused vaccine at time of administration with no attempted administration date noted on the consent forms.There is no documentation in R11's Electronic Medical Record (EMR) of any attempts to provide R11 with the influenza vaccine at a later date and/or any conversations with R11's provider 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 interview and record review the facility repeatedly failed to notify the Physician of one (R1) resident's elevated glucose levels out of three residents reviewed for Quality of Care in a sample list of eight residents.Findings include:R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. R1's Physician Order Sheet dated August documents a physician order to obtain R1's blood glucose levels twice daily. R1's Electronic Medical Record (EMR) does not show that V17 (R1's) Physician was notified of R1's blood glucose levels above 200 mg/dl.R1's Medication Administration Record (MAR) dated August 2025 document R1's blood glucose level were:8/12/25 at 5:00 PM was 2138/18/25 at 9:00 AM was 2208/19/25 at 9:00 AM was 2728/20/25 at 9:00 AM was 2488/23/25 at 9:00 AM was 2858/24/25 at 9:00 AM was 3008/24/25 at 5:00 PM was 2068/25/25 at 9:00 AM was 2988/25/25 at 5:00 PM was 2218/26/25 at 9:00 AM was 3068/27/25 at 5:00 PM was 2218/28/25 at 5:00 PM was 2358/29/25 at 9:00 AM was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility repeatedly failed to administer one (R2) resident's Latanoprost 0.05% eye drop medication as prescribed out of five residents reviewed for medication administration in a sample list of eight residents.Findings include:R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact.R2's Physician Order Sheet (POS) dated September 2025 documents a physician order starting 8/15/25 to administer Latanoprost 0.005% eye drops, one in each eye at bedtime for eye deficiencies. R2's Care Plan intervention dated 8/15/25 instructs staff to Administer medication per orders.R2's undated Pharmacy medication fill report documents R2's Latanoprost Ophthalmic solution 0.005% eye drops have an original date of 8/15/25 and fill dated of 8/26/25 and 9/12/25. R2's Medication Administration Record (MAR) dated August 2025 documents R2's Latanoprost 0.005% Ophthalmic Solution eye drops was not administered on 8/15, 8/16, 8/18 and 8/20-8/25/25 due to medication not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to check the placement of one (R3) resident's Gastrostomy Tube (G-Tube) prior to administering medication out of eight residents reviewed for medication administration in a sample list of eight residents. Findings include:R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 as being dependent on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R3's Physician Order Sheet (POS) dated September 2025 documents a physician order for R3 to not take any foods/medications by mouth (NPO). This same POS documents a physician order starting 8/15/25 to administer Jevity 1.5 calorie/Fiber Oral Liquid (Nutritional Supplements) Give 240 milliliters (ml) via Gastrostomy tube (G-Tube) four times a day for Dysphagia. This same POS documents a physician order starting 8/15/25 to check G-Tube residual amount and record before administering feeding every…

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 follow Infection Control Procedures for one (R3) resident on Enhanced Barrier Precautions (EBP) out of five residents reviewed for medication administration in a sample list of eight residents.Findings include:R3's Physician Order Sheet (POS) dated September 2025 documents a physician order for R3 to not take any foods/medications by mouth (NPO). This same POS documents a physician order starting 8/14/25 for staff to utilize Enhanced Barrier Precautions (EBP) every shift during high contact care activities that provides opportunities for transfers of Multi Drug Resistant Organisms (MDRO) from/to high-risk residents with wounds and/or indwelling medical devices that are at especially high risk for both acquisition of and colonization of MDRO's. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 as being dependent on staff for oral hygiene, toileting, bathing, dressing, personal…

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 medical records are complete and accurate for four of seven residents (R1, R2, R3, R7) reviewed for changes in condition and elopement in the sample list of nine. The facility's Content of the Medical Record policy dated August 2017 documents the Administrator is responsible for ensuring medical records are maintained according to regulations and guidelines. This policy documents medical records should include documentation of resident care, observations, assessments and changes in condition. This policy documents physician and consultant visits should be recorded at the time of each visit. 1.) R1's 8/13/25 and 8/19/25 Provider Progress Notes with print date 9/2/25 were provided by V2 Director of Nursing (DON) on 9/2/25. These visit notes were not uploaded into R1's Electronic Medical Record (EMR). On 9/3/25 at 10:00 AM, V2 and V25 both confirmed provider progress notes are not consistently uploaded into each resident's EMR, including R1, R2, and R3. V2 stated these notes have to be pulled off of (electronic health…

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

Based on Interview, Observation and Record Review the facility failed to notify the physician and power of attorney for an incident of elopement for one (R7) of three residents reviewed for elopement on a sample list of nine. On 9/2/2025 at 12:37PM, V10 Licensed Practical Nurse (LPN) stated V10 did not complete an assessment, notify R7's physician or family, and didn't follow the Facilities Missing Resident Policy for R7's elopement from the facility on 8/31/25. On 9/2/2025 at 1:10PM, V1 Administrator stated he was unaware of the situation that had occurred with R7 as it wasn't reported to V1 and V1 just initiated an investigation into the incident. Video surveillance was viewed with V1 at this time. On 8/31/25 between 8:55 AM and 9:07 AM, R7 left the facility through the southwest alarmed door of the memory care unit walking across the parking lot and grass lot, towards a church located next to the facility. R7 was found by V18 (R9's Family) at the church, which is located approximately a football distance away from the facility door. At 9:10 AM, V10 Licensed Practical Nurse 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 interview and record review the facility failed to transcribe physician's orders for one of four residents (R3) reviewed for accidents in the sample list of nine. On 8/27/25 at 9:30 AM, R3 was sitting in her wheelchair in her room. R3's right leg was in a splint and elevated on the wheelchair leg rest. R3 stated that V3 Physical Therapy Assistant was pushing R3 in a wheelchair down to the therapy gym, R3's feet were sticking out and the wheelchair did not have foot pedals. R3 stated R3 had difficulty holding her legs up, R3's right foot went underneath of R3 causing R3's ankle to roll or twist and R3 screamed out in pain. R3 stated R3 has two broken ankle bones because of that incident. R3's right ankle x-ray dated 8/23/25 documents R3 has severe osteopenia (low bone mineral density), R3 had Subtle linear lucencies noted through the medial and lateral malleoli suspicious for acute nondisplaced fractures and soft tissue swelling. R3's emergency room Note dated 8/22/25 at 11:09 PM documents R3 presented for ankle pain after being pushed in a wheelchair to therapy while R3'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 interview and record review the facility failed to administer medications as ordered resulting in significant medication errors for one of five residents (R2) reviewed for changes in condition in the sample list of nine. R2's hospital discharge orders dated 7/22/24 include orders for Metoprolol Succinate (cardiac medication) Extended Release 12.5 milligrams (mg) by mouth (PO) daily, Midodrine (treats low blood pressure)10 mg PO three times daily, and Novolog insulin per blood glucose-based sliding scale three times daily before meals. R2's July 2025 Medication Administration Record documents R2's Metoprolol, Midodrine, and Novolog insulin were stopped on 7/23/25 and R2 did not receive any doses of these medications after the morning dose on 7/23/25 prior to being hospitalized on the evening of 7/24/25. There is no documentation in R2's medical record as to why these medications were stopped or that the physician was notified of the missed doses. On 9/3/25 at 10:00 AM, V25 Assistant Director of Nursing stated on 7/23/25, V25 thought R2 was still in the hospital and did 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 protect a resident's right to privacy. This failure affects one resident (R1) of three reviewed for privacy in the sample of six. This past non-compliance occurred from 7/10/2025 to 7/16/2025.Findings include:R1's diagnosis list (8/7/2025) documents diagnoses including Dementia, Hemiplegia (paralysis or severe weakness on one side of the body), Cerebral Infarction (stroke), and Major Depressive Disorder. R1's Resident Assessment (6/4/2025) documents R1 has severe cognitive impairment, is immobile, and is dependent on staff for mobility and performing activities of daily living. The facility incident report (7/16/2025) documents V6 (formerly employed as a Certified Nurse Aide in the facility) had taken an unauthorized video of R1 with V6's cell phone. The report documents the video was no longer stored on V6's phone but a copy existed in V6's digital cloud storage. The report further documents access to V6's cloud storage was shared with V9 (V6's boyfriend) and V8 (mother of V9) subsequently had accessed 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 report a resident fall to the licensed nurse, directly resulting in a lack notification of the residents physician and family member. This failure affects one resident (R1) out of one reviewed for notifications on the sample list of six. This past compliance occurred from 6/20/25 and 7/1/25. Findings include: On 7/1/25 at 10:39 AM, V3, Family Member and legal Power of Attorney for R1, stated that the facility had not notified her of R1's most recent fall. V3 stated she had found out about R1's fall during a conversation with a friend (unidentified) who worked at the facility. R1's comprehensive Electronic Medical Record did not document any actual recent fall event experienced by R1. R1's Nurses Notes dated 6/20/25 documented facility staff held a care plan conference for R1 attended by V3. R1's Nurses Notes dated 6/21/25 document one post fall neurological check conducted by V15, Licensed Practical Nurse. R1's Assessment record documented further neurological checks beginning with the documented one 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 staff failed to report a resident fall to the licensed nurse, directly resulting in a lack of a licensed nurse completing a nursing assessment and a neurological assessment prior to picking the resident up from the floor. This failure affects one resident (R1) out of one reviewed for fall reporting on the sample list of six. This past compliance occurred from 6/20/25 and 7/1/25. Findings include: On 7/1/25 at 2:40 PM, V10, Registered Nurse Manager, stated R1 did experience a fall on 6/19/25. V10 stated she had only found out about the fall because V3, Family Member of R1, had attended a care plan conference on 6/20/25 and made an inquiry as to why she (V3) was not notified of R1's fall the day prior to the care plan conference. V10 stated she had found that V16, Certified Nursing Assistant, had picked R1 up from the floor without notifying the licensed nurse. On 7/1/25 at 2:50 PM, V16 stated she had gone into R1's room to deliver a meal tray and found R1 on the floor by the bed. V16 stated she could not locate the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident right to be free from verbal abuse (R3) by another resident (R2) and failed to protect a resident right to be from physical abuse (R3) by another resident (R2). R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnosis; Spastic Quadriplegic Cerebral Palsy, Seizures, Quadriplegia, Obstructive Sleep Apnea, Anxiety Disorder, Hyperlipidemia, Deficiency of Specified B Group Vitamins, Schizophrenia, Esophagitis without Bleeding, GERD, Insomnia, Functional Quadriplegia, HTN, Depression, Retention of Urine and Personal History of Malignant Neoplasm of Testis. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 6, severe cognitive impairment and is dependent on staff's assistance with Activities of Daily Living. R2's Care Plan dated 6/21/23 documents R2 potential for abuse and neglect due to current cognition, medical condition and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an injury of an unknown origin to the state survey agency for one (R6) of three residents reviewed for injuries in the sample list of 8. Findings include: Facilities Accidents and Incidents Policy dated November 2023 documents. Purpose: To provide staff with guidelines for investigating, reporting, and recording Accidents and Incidents. Policy: All accidents/incidents involving a resident, visitor or volunteer will be investigated, and then recorded in Risk Management of Electronic Health Record. Incident reports will be retained in accordance with State statue of limitations and record retention laws. Procedure: 1. Reporting an Accident and Incident: A. Accident and incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an Accident/Incident Report Form must be completed on the shift the accident/incident occurred. 4. Investigate and follow/up Action: A. The charge nurse must conduct an immediate…

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 one (R1) of three residents reviewed for pressure ulcers in the sample list of four. Findings include: The facility's Enhanced Barrier Precautions policy dated 10/21/22 documents EBP expands the use of gloves and gowns to be worn during high-contact care activities that provides opportunities for Multidrug Resistant Organisms (MDROs) to be transferred between staff hands or clothing and between residents during these high-contact cares. This policy documents residents with wounds and indwelling medical devices are at high risk of acquisition and colonization of MDROs. This policy documents to wear gown and gloves when assisting residents on EBP with high-contact care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, providing device care or wound care. R1's readmission Skin 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 timely report post fall pain and implement radiology orders timely, resulting in a delay in treatment of a left hip fracture for one (R4) of three residents reviewed for falls in the sample list of eight. Findings include: The facility's Acute Condition Changes - Clinical Protocol dated June 2023 documents the nurse should assess, document and report changes in pain level. Nursing staff will contact the physician based on the urgency of the situation and the physician will be paged/called requesting prompt response, approximately one half hour or less, for emergencies. This policy documents the nursing staff and the physician will discuss possible causes including resident history and symptoms, and the physician will order diagnostic testing or directly evaluate the resident if necessary. This policy documents the physician will review the status of the condition change and document the evaluation, including the significance of the acute change, at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide bathing, oral care, and toileting for three (R1, R2, and R4) of four residents reviewed for dependent activities of daily living from a total sample list of four. Findings include: The facility provided Activities of Daily Living Policy dated 7/2024 documents that all residents will have activities of daily living (bathing, oral care, perineal care) provided by nursing staff as needed in accordance with each individual's needs and that it is the responsibility of both the Certified Nursing Assistants and Charge Nurse to ensure that the care is being provided and documented in the electronic health record. 1.) R1's Minimum Data Set, dated [DATE] documents R1 is severely cognitively impaired. R1's Minimum Data Set, dated [DATE] documents R1 is totally dependent for bathing, dressing, toileting and oral care. R1's local hospital admission record dated 2/4/25 documents that R1 was admitted to the local hospital with thick hardened 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 identify, assess, make the appropriate notifications, obtain treatments and interventions for three pressure wounds for one (R1) of four residents reviewed for pressure wounds from a total sample list of four residents. Findings include: The facility provided Skin and Wound Management Guidelines Policy dated 4/2024 documents that upon admission or readmission a complete skin assessment is to be done and documented. If a wound is present on admission, ensure that there is a treatment order, notify the resident's representative, and initiate care plan interventions. The facility provided wound report dated 2/10/25 documents that R1's only wound is a wound on her right middle finger that was identified on 1/30/25. R1's progress notes dated 2/4/25 document that R1 was transferred to the local hospital for a change of condition including decrease consciousness and tachypnea. R1's hospital admission notes dated 2/4/25 document's R1 has stage one to two changes at the coccyx and a stage one pressure ulcer injury 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 accurately encode Minimum Data Sets to reflect resident status with regards to falls experienced and severity of injuries incurred. This failure affects three residents (R1, R2, R4) out of four reviewed for falls and injuries. Findings include: 1. On 1/21/25 at 1:10 PM, R1 was on the facility's dementia care unit wearing a padded helmet. R1's emergency room Reports dated 12/20/24 document R1 had experienced a subdural hematoma without bleeding, a laceration on the right temporal scalp requiring three sutures to close, and a non-displaced fracture of the right wrist during a fall at the facility on this same date. R1's Nurses Notes dated 12/18/24 document R1 had experienced a fall on this date with no apparent injury. R1's Nurses Notes dated 11/28/24 document R1 had experienced a fall on this date with no apparent injury. R1's Nurses Notes dated 11/16/24 and experienced a hematoma (raised bruise) on the back of her head. R1's Minimum Data…

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 observations, interviews, and record reviews, the facility repeatedly failed to implement fall interventions for R1, R2, and R3 and repeatedly failed to complete R2's quarterly fall risk assessments. These failures affected three of the three residents (R1, R2, and R3) reviewed for falls on the sample list of seven. Findings include: 1.) R1's Census Record dated 10/18/24 documents that R1 was admitted to the facility on [DATE]. The same census record documents the following: Special Instructions: 1 (one) person transfer with gait belt and RW (roller walker). Ensure TLSO (Thoracolumbar sacral orthosis, type of support to promote healing of spinal fractures) brace is on when OOB (out of bed). R1's current Diagnoses Sheet, with multiple dates, documents the following diagnoses: Repeated Falls (dated 9/26/24), Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety (dated 02/18/24), Multiple Fractures Of Ribs,…

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 record review and interview, the facility failed to notify a resident's family representative of positive laboratory test results for an infectious disease and failed to notify both the family representative and a physician/nurse practitioner of a significant decline in a resident's level of consciousness, abnormal lung assessment, and a productive cough. This failure affected one of four residents (R4) who were reviewed for changes in condition on the sample list of seven. Findings include: R4's Diagnoses Sheet, dated 10/22/24 at 12:13 pm, documents the following: Alzheimer's Disease and Unspecified Dementia Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R4's Minimum Data Set, dated [DATE] documents R4's Brief Interview of Mental Status score as four out of a possible 15, indicating severe cognitive impairment. R4's Orders - General Note dated 10/18/24 at 1:46 pm (day shift) documents: Late Entry (unidentified time of covid test): Note Text: NP (V18,…

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 record review and interviews, the facility repeatedly failed to maintain complete and accurate resident medical record, by failing to document the application of a physician ordered back brace. This failure affected one of seven residents (R1) reviewed for complete medical records, on the sample list of seven. Findings include: R1's current Diagnoses Sheet documents the following diagnoses: Dementia, and Vertebral fractures. R1's Physician Order Summary Report dated 10/18/24 documents the following: UP with one assist, with gaitbelt and RW (roller walker); TLSO (speciality, back) brace ON when out-of-bed; Increase activity as tolerated. Active (as of) 09/26/2024. R1's Electronic Medication/Treatment Administration Records dated 9/26/24- 9/30/24 (five days) and 10/1/24 - 10/19/24 (19 days) dose not have nurses initials in the administration box to confirm R1's physican order for the TLSO back brace was in place, when R1 was out of bed. On 10/23/24 at 8:25 am V2, Director of Nursing reviewed R1's MAR/TAR and stated I have updated the error in (R1's) back (TLSO) brace order.…

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 the interview and record review, the facility failed to properly transfer one of two residents (R1) reviewed for peripherally inserted central catheter (PICC) maintenance on the sample list of three. This past noncompliance occurred from 8/29/24 through 9/7/24. Findings Include: The facility's PICC/Central Venous Catheter Dressing Changes policy, dated 9/1/23, states that PICC/Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, soiled, or wet dressings. Transparent semi-permeable dressings are changed every seven days or as needed. R1's Minimum Data Set, dated [DATE] documents that R1 is cognitively intact. R1's Medical Diagnoses Sheet, dated September 2024, documents that R1 is diagnosed with Osteomyelitis. R1's Physician Order Sheet dated September 2024 documents an order for Daptomycin-Sodium Chloride Intravenous Solution - 1000 milligrams intravenously, every 24 hours, 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.

Based on interview and record review, the facility failed to maintain residents' dignity by failing to answer call lights and respond to requests for assistance in a timely manner. This failure affects eight residents (R1, R2, R6, R8, R9, R20, R21, and R23) out of 17 reviewed for call light response times on the sample of 35. Findings include: On 9/4/24 at 10:25 AM, R6 stated, The call lights can take up to 30 minutes for someone to answer. On 9/4/24 at 10:45 AM, R8 stated, At times the call lights take longer to answer than I would like. The staff do come clean me up when I get wet or soiled. There are times when someone will answer my call light and say 'I'll be right back,' but they don't come right back. On 9/4/24 at 11:05 AM, R2 stated, The call lights do take a long time especially during meal times. It does happen sometimes that someone answers the light and says they will come back but then they don't unless I push the light again. On 9/4/24 at 12:20 PM, R9 stated, The call lights can take up to 45 minutes for someone to come. Once in a great while someone will come real…

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 maintain flooring in resident bathrooms in a clean, safe, and homelike manner. This failure affects 15 residents (R7, R8, R12, R22, and R25 through R35) out of 23 reviewed for environmental concerns on the sample of 35. Findings include: On 9/4/24 during an environmental tour beginning at 10:25 AM, the bathroom vinyl floor in room [ROOM NUMBER] had ground in dirt and stains which would rub off with a dry piece of bathroom tissue. R7 stated, They just cleaned in here about 45 minutes ago. The bathroom vinyl floor connecting rooms [ROOM NUMBERS] had age-related ground in dirt and stains. The dirt portions could be rubbed off with a dry piece of bathroom tissue. The stained portion was imbedded in the vinyl. The bathroom vinyl floor connecting rooms [ROOM NUMBERS] had dark ground in dirt which could be rubbed off with a dry piece of bathroom tissue, rusty colored stains around the toilet imbedded in the vinyl, cracks approximately 14 inches long and…

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

Based on interview and record review, the facility failed to report an allegation of mental abuse to the state agency in the 2 hour required timeframe. This failure affects one resident (R1) out of twelve reviewed for abuse on the sample of 35. Findings include: On 9/4/24 at 8:55 AM, V1 stated, (V7, Family Member of R1) called me to complain that a staff member had woken (R1) in the middle of the night and (R1) wasn't happy about it. V1 further stated, I will have to go check my 'soft file' to see if the employee was suspended. On 9/5/24 at 9:02 AM, V1 stated, What happened was I received a phone call from (V7) that a staff member was rude to (R1) during the night (allegation). V1 continued, I was at the facility so I went down to talk with (R1) (investigation). V1 then stated, (R1) told me a CNA (Certified Nursing Assistant) had startled her awake during the night (early 8/22/24). Then I called (V5) and informed her I had a potential allegation and had to suspend her for now. V1 further stated, I had (V4, Assistant Administrator) go and speak with other residents to find out how…

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 record review and interviews the facility failed to protect two residents from misappropriation of property by facility staff. This failure caused R1 to have 11 transactions totaling $1515.96 being misappropriated from R1's private bank account. This failure affects two (R1, R2) residents on the sample list of three reviewed for misappropriation of personal property. Findings include: The Physicians Order Sheet dated July 2024 documents R1 has the following diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Acquired absence of Right Leg Above the Knee, and Type 2 Diabetes Mellitus with Hyperglycemia. R1 moves about the facility with an electric wheelchair that she is able to operate without difficulty. R1 requires total assistance with all daily activities. R1's Minimum Data Set (MDS) assessment date 05/02/24 Section C Brief Interview Mental Status (BIMS) documents R1 has a score of 15 which is cognitively intact. Facility investigation documents: - R1 reported to V1 (Administrator) on June 27, 2024 at 10:52 AM that her…

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

Based on interview and record review the facility failed to protect the residents' right to be free from misappropriation of property by failing to follow the facility's Abuse Prevention Program by staff taking photographs of residents (R1, R2) personal property and sharing the photographs with another person. R1 and R2 are two residents reviewed for abuse in the sample list of three. Findings Include: The facility's Abuse Prevention Program dated 10/20/2022 documents the facility affirms the right of it's residents to be free from misappropriation of property. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belonging or money without the resident's consent. The facility's policy titled further documents under the section titled Policy This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone . The Policy continues to state under the section titled Establishing a Resident Sensitive Environment documents under…

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 interventions were in place, safely position a resident on a low air loss mattress, keep necessary items within reach for a resident, and store a rolling chair away from resident areas. The facility also failed to complete post fall assessments, transfer a resident post fall according to facility policy, and thoroughly investigate falls. These failures affect three of three residents (R1, R4, R5) reviewed for falls on the sample list of seven. Findings include: 1. R1's undated Medical Diagnosis List documents R1's medical diagnoses as Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, Neurological Neglect Syndrome, Paralytic Syndrome following Cerebral Infarction affecting Left Non-Dominant side, Nontraumatic Intracerebral Hemorrhage, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side, Seizures, Kidney Failure, Protein Calorie Malnutrition, Dysphagia, Cognitive communication…

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 record review and interview the facility failed to ensure a resident right to dignified care and treatment. This failure affects one of three residents (R3) reviewed for dignity/abuse on the sample list of three. Findings include: R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a brief interview of Mental Status score of 13 out of a possible 15, indicating no cognitive impairment. The same MDS documents R3 is incontinent of bowel and bladder, frequently. R3's Diagnoses Sheet dated 3/11/24 documents the following: Anxiety Disorder Unspecified, Other Fatigue, Irritable Bowel Syndrome with Diarrhea, and Benign Neoplasm of Unspecified Part of Small Intestine. R3's Care Plan dated 4/9/24 documents (R3) has Bowel & bladder incontinence, R3 will remain free from skin breakdown due to incontinence and brief use through the review date, and (R3) has a need for assistance during transfers. On 5/7/24 at 12:30 pm V10, Auxiliary Assistant was interviewed regarding abuse. V10 stated the following: Anything…

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 protect a residents' right to be free from verbal/mental abuse by another resident. This failure affects two of three residents (R1 and R2) reviewed for abuse on the sample list of three. Findings include: R2's Diagnoses Sheet dated 5/1/24 documents the following: Unspecified Dementia, Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. R2's Brief Interview of Mental Status (BIMS) on admission 5/1/24 score is documented as 4 out of a possible 15, indicating severe cognitive impairment. R2 admission Note dated 5/01/24 at 3:07 pm documents R2 ambulates with a walker. R1's Diagnoses Sheet dated 5/5/22 documents the following: Hemiplegia and Hemiparesis Following a Cerebra Infarction Affecting Left Non-Dominant Side, Chronic Obstructive Pulmonary Disease Unspecified, Major Depressive Disorder Recurrent, and Unspecified and Anxiety. R1's diagnoses sheet does not document a diagnoses 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 record review and interview the facility failed to ensure an allegation of physical and verbal abuse by R2 towards R1, was reported to the Administrator/Abuse Prevention Coordinator. This failure resulted in R1 and R2 continuing to reside in the same bedroom, potentially subjecting R1 to further abuse by R2. R1 and R2 are two of three residents reviewed for abuse on the sample list of three. Findings include: R2's Incident Note dated 05/05/2024 at 2:21 pm, by V4, Licensed Practical Nurse (LPN) documents the following: After lunch the Resident (R2) became physically violent with her roommate (R1). The housekeeper (V3) reported that the resident (R2) was pulling her roommates (R1's) hair before her roommate (R1) threw her water jug at her (R2) to stop her from pulling her (R1's) hair. Resident (R2) was removed from her room and redirected to the tv (television) lounge. POA (V22, Power of Attorney/Family Member) was notified about the incident, and her (R2's) other (Family Member, V16) came to help calm her (R2) down. Resident (R2) keeps accusing her bedridden roommate (R1) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure two staff were assisting during a mechanical lift transfer for one of four residents (R2) reviewed for falls on the sample list of four. This past noncompliance occurred from 4/20/24 to 4/25/24. Findings include: The Physician's Order Sheet (POS) dated April 2024 documents the following diagnoses for R2: Chronic Obstructive Pulmonary Disease, Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure and Morbid Obesity. The Minimum Data Set (MDS) dated [DATE] documents R2 is independent in decision making skills, uses an electric wheelchair for transportation needs, and activities of daily living are completed by staff due to R2's medical diagnoses. R2's care plan dated 3/8/24 documents R2 requires two staff assistance for all transfers. Mechanical lift transfer requires two staff to be present. Facility incident report dated April 20, 2024, documents on April 20, 2024, at approximately 2:00 pm, V12, Certified Nurse…

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 notify the physician of a resident refusal of catheterization for one (R1) of three residents reviewed for physician notification on the sample list of three. Findings include: R1's progress notes dated 2/26/24 document that R1 was complaining of burning with urination. R1's progress notes dated 2/26/24, document V6 Nurse Practitioner ordered a urinalysis with a culture and sensitivity to be obtained on R1. R1's progress notes dated 2/26/24 through 2/29/24 document that R1 refused to have a catheterization performed for the urinalysis, with culture and sensitivity. R1's medical record does not document that the physician was notified that R1's urinalysis with culture and sensitivity was not collected from 2/26/24 through 2/29/24. R1's progress notes document that R1 was discharged to a local hospital on 2/29/24. R1's hospital discharge record dated 3/9/24 documents that a catheterization was performed on R1 upon hospital admission that resulted in a positive urinalysis that grew Klebsiella Pneumoniae (ESBL) and was then…

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 administer narcotic medications safely to one (R1) of three residents reviewed for narcotic administration on the sample list of three. Findings include: The Physician Order dated 2/19/24 documents to give R1 one Oxycodone-APAP 5-325 milligram tablet three times a day for pain. The controlled drug receipt/record/disposition form dated 2/20/24 documents on 2/29/24 at 10:00AM, one Oxycodone/APAP 5-325 milligram tablet (narcotic) was given to R1 by V4 LPN/Licensed Practical Nurse. The controlled drug receipt/record/disposition form dated 2/20/24 documents on 2/29/24 at 1:00PM, one Oxycodone/APAP 5-325 milligram tablet (narcotic) was given to R1 by V4 LPN. On 3/11/24 at 9:30AM, V7 Certified Nursing Assistant (CNA) stated that on the morning of 2/29/23, V7 CNA had gone into R1's room to answer a call light for one of R1's roommates and saw R1 lying in bed without wearing her oxygen and without wearing any clothing. V7 CNA stated that he asked R1 what was going on and R1 was lethargic and slow to respond, not like R1's usual…

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 revise and update a resident's (R1) Plan of Care to include Gastrostomy Residual Volume checks before each enteral feeding. R1 is one of three residents reviewed for Care Plans in the sample of three. Findings include: R1's Diagnosis Sheet (current) includes the following diagnoses: Dysphagia Status Post Cerebral Vascular Accident, Chronic Cholecystitis, Gastrostomy Status and Left Sided Hemiparesis. R1's Care Plan (current) documents G Tube (Gastrostomy Tube) placement R/T (Related To) Dysphagia and initiated on 6/4/23. Intervention tasks are documented as Check G Tube placement as ordered. Flush G Tube as ordered. Check for Patency of G Tube, Monitor area around Stoma for S/S (Sign and Symptoms) of Infection. There is no intervention for Gastrostomy Residual Volume (GRV) checks and parameters for holding the tube feeding prior to administration when residuals exceed a certain amount. R1's Physician Order Sheet (POS) dated 2/8/24 documents an order for R1's G Tube to be checked for residuals prior to feeding and if 100…

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 have physician orders in place regarding Gastrostomy Residual Volumes (GRV) check with result parameters prior to starting tube feedings for three (R1, R2, R3) of three residents reviewed for tube feedings in the sample of three. Findings include: 1. R1's Diagnosis Sheet (current) includes Gastrostomy Status. R1's Physician Order Sheets (POS) dated December 2023, January and February 2024 do not document any orders prior to 2/8/24 for the facility to check GRV's before starting tube feedings. These same POS's document R1 with continuous tube feedings. R1's Progress Notes document the following: On 1/30/24 at 1:03 pm - The patient had an emesis this shift, the same color as (R1's) feeding while receiving a bed bath this a.m./morning. This Nurse (V4 Licensed Practical Nurse) and CNA (V5 Certified Nursing Assistant) were rolling the patient from side to side and the patient vomited. The patient had been flushed prior to that morning. On 2/1/24 at 7:11 am…

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 implement its policies to accurately record and account for controlled medications for 28 of 28 residents (R1, R2, R3, R9-R33) reviewed for controlled medications in the sample list of 33. Findings include: 1.) On 1/30/24 at 8:59 AM the medication cart and controlled medication binder for 1st floor [NAME] Hall was reviewed with V4 Licensed Practical Nurse (LPN). The last recorded entry on the controlled substance shift to shift count is 2:00 PM-10:00 PM, indicating the form is not up to date/current to account for shift count between nights and dayshift. This entry only includes one nurse signature and not two as indicated. V4 stated controlled medication counts are to be done with two nurses at change of shift, both nurses sign the count sheet, and the number of cards and bottles are also counted. V4 stated the count was done this morning, but the form doesn't document the nurse signatures for this count. At this time V4 documented on the controlled count form an untimed entry date of 1/30 and V4's initials.…

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 thoroughly investigate an injury of unknown origin for one of four residents (R6) reviewed for injuries in the sample list of 33. Findings include: The facility's Illinois Department of Public Health reporting form dated 1/23/24 documents on 1/23/24 at 8:44 PM the facility received a phone call from the hospital reporting bruising to R6's genital area that appears to be of unknown origin, and an investigation was initiated. This report documents this incident as suspected abuse/neglect. The facility's undated investigation of R6's bruising documents R6 was sent to the hospital on the afternoon of 1/23/24 and the emergency room nurse noted bruising to R6's penis and testicles. This investigation documents V8 Licensed Practical Nurse (LPN) provided a statement that attempts were made to obtain urinalysis due to increased lethargy on 1/22/24, and R6 became combative/agitated during the procedure. R6 struggled against the nurse's hold during attempt of catheter insertion and R6 receives Plavix (blood thinning medication). This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications in accordance with physician's orders for two of five residents (R5 and R9) reviewed for medications in the sample list of 33. Findings include: The Medication Error Form dated 1/13/24 at 5:00 PM documents V12 Registered Nurse (RN) administered the wrong medications to R5. The medications given were Metformin (diabetic medication) 500 milligrams (mg), Duloxetine (antidepressant) 60 mg, Omeprazole (treats heartburn, ulcers, reflux) 40 mg, Pregabalin (controlled medication for pain) 200 mg, and Topiramate (seizure medication) 100 mg. This form documents V12 prepopped medications and inadvertently administered the wrong medications to R5. This form documents V12 was educated not to prepop medications and a photograph was placed in R5's medical record that day. R5's Order Summary dated 1/13/24 documents R5 admitted to the facility on [DATE] and R5's orders did not include the medications listed as given in the Medication Error Form.…

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 complete performance reviews to identify training needs and provide training for CNAs (Certified Nursing Assistants). This failure has the potential to affect all 158 residents who reside in the facility. Findings Include: The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) documents 158 residents reside at the facility. The Facility's Assessment tool dated December/2022 through November/2023 states Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours every year. Include dementia management training and resident abuse training. Address areas of weakness as determined in nurse aide's performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurse's aides providing services to individuals with cognitive impairment, also address the care of the cognitively impaired. On 11/14/23 at 11:00AM V1, Administrator stated…

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 all Certified Nurse's Aide's (CNA) received twelve hours of annual training including required subjects. This failure has the potential to affect all 158 residents residing in the facility. Findings Include: The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) documents 158 residents reside at the facility. The Facility's Assessment tool dated December/2022 through November/2023 states Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours every year. Include dementia management training and resident abuse training. Address areas of weakness as determined in nurse aide's performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurse's aides providing services to individuals with cognitive impairment, also address the care of the cognitively impaired. On 11/14/23 at 11:00AM V1, Administrator stated The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess the need for psychotropic medication upon admission and quarterly for four of five (R73, R63, R134, R80) residents reviewed for psychotropic medications on the sample list of 77. Findings include: The facility's Psychotropic Medications Policy with a revision date of February/2021 documents under procedures that, 4. Psychotropic medications will have a nursing Psychotropic Medication Assessment completed on admission or with changes to any psychotropic medications ordered for the resident. This policy also documents, 8. Each resident taking antipsychotic/psychoactive medications shall have their medications reviewed and documented by a physician 2 times a year, monthly by the Pharmacy Consultant and quarterly or as needed by the Interdisciplinary Team. 1. R73's Medication Administration Record (MAR) dated November of 2023 documents an order dated 7/24/23 for Clonazepam (antianxiety) one milligram by mouth once a day, an order dated 9/6/23 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.

Based on observation, interview and record review the facility failed to dispose of undated insulin for seven (R104, R51, R68, R1, R134, R119, R64) of seven residents reviewed for medication storage from a total sample list of 77 residents. Findings include: The Long-Term Care Facility Application for Medicare and Medicaid dated 11/13/23 documents 158 residents reside in the facility. The facility provided insulin drug manufacturer instructions document that multidose Lantus, Novolog and Humalog Insulin vials and pens must be disposed 28 days after opened. The facility provided insulin drug manufacturer instructions document that multidose Levemir Insulin vials and pens must be disposed 42 days after opened. On 11/14/23 at 8:42AM, V8 Licensed Practical Nurse (LPN) confirmed that R104's Novolog Insulin vial, R51's Levemir Insulin vial, and R68's Lantus Insulin vial were open without opened on dates. Additionally, V8 LPN confirmed that stock Glargine Insulin vial, was without an opened-on date. On 11/14/23 at 9:00AM, V9 LPN confirmed that R1's Lantus Insulin and R134's Lantus Insulin…

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

Based on interview and record review the facility failed to provide Advance Beneficiary Notices (ABN) to three of three residents (R264, R146, and R6) reviewed for Beneficiary Protection Notifications on the sample list of 77. Findings include: 1. R264's Beneficiary Protection Notification Review form provided by V1 Administrator, documents R264's Medicare start date as 10/17/23. This form documents R264's last covered Medicare day as 11/2/23. This form documents the facility/provider initiated R264's discharge from Medicare Part A Services when benefit days were not exhausted. This form documents a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) was not provided. The explanation handwritten on the form documents, (the facility) was not aware that business office manager was to complete ABN upon takeover.) On 11/15/23 at 8:30 AM, V1 Administrator stated an Advanced Beneficiary Notice should have been provided to R264. V1 stated an ABN was not completed for R264. 2. R146's Beneficiary Protection Notification Review form provided by V1 Administrator, documents R146's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide nail care to one of 31 residents (R56) reviewed for Activities of Daily Living in the sample list of 77. Findings include: The facility's Activities of Daily Living policy with a revised date of June 2023 documents, All residents will have activities of daily living provided by nursing staff as needed in accordance with each individual's needs. Responsibility: It is the responsibility of the C.N.A. (Certified Nursing Assistant) to provide activities of daily living to residents as required for everyone. It is the responsibility of the Charge Nurse to ensure that activities of daily living have been provided to all residents on each unit. Procedure: 12. Provide nail care. The facility's Nail Care (Finger & {and} Toes) policy with a revised date of February 2020 documents, Nail care will be provided for all residents in order to provide cleanliness, prevent spread of infection, for comfort, and to prevent skin problems. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have fall prevention interventions in place on admission for one of two residents (R215) reviewed for falls in the sample list of 77. Findings include: The facility's Accident/Incident log provided by the facility on 11/13/23 documents R215 sustained falls on 10/2/23 and 10/25/23. R215's Minimum Data Set (MDS) dated [DATE] documents R215 was admitted to the facility on [DATE] from the hospital and documents R215 has severe cognitive impairment and has impaired range of motion on both upper extremities and one side of the lower extremities. This MDS documents R215 is dependent with walking. R215's Fall Risk assessment dated [DATE] documents R215 is at high risk for falls. R215's Care Plan dated 10/12/23 documents R215 requires two assist with transfers and documents on 10/2/23 that R215 is at high risk for falls. R215's unsigned and undated baseline care plan for the admission date of 9/27/23 documents R215 had a history of falls but does not document…

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 before or after administering medications and obtaining a blood glucose level for five (R52, R119, R64, R415 and R156) of five residents reviewed for medication administration on the sample list of 77. Findings include: The facility provided Hand Washing Policy dated March/2021 documents that all staff will properly wash hands after direct contact with any contaminated substance, after direct resident care, and as instructed. The use of gloves does not replace handwashing/hand hygiene. On 11/13/23 at 3:23PM, V17 Licensed Practical Nurse (LPN) provided medication to R52 without washing or sanitizing V17's hands before or after administering medications. On 11/13/23 at 3:31PM, V17 LPN provided medication to R119 without washing or sanitizing V17's hands before or after administering medications. On 11/13/23 at 3:39PM, V17 LPN provided medication to R64 without washing or sanitizing V17's hands before or after administering medications and V17 LPN obtained R64's blood sugar without washing 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, interview and record review the facility failed to ensure the dignity of residents. This failure affects two (R3, R4) out of three residents reviewed for Activities of Daily Living in a sample list of nine residents. Findings include: 1.) R3's Electronic Medical Record (EMR) documents medical diagnoses of Chronic Systolic Congestive Heart Failure, Moderate Protein-Calorie Malnutrition, Gastroesophageal Reflux Disease without Esophagitis, Atherosclerotic Heart Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, (COPD), Atrial Fibrillation and Anemia. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as modified independent for daily decision making. R3's Care plan includes interventions dated 5/31/23 of Aspiration Precautions, cue R3 to take small bites or small sips one at a time, encourage to eat slowly, ensure R3 is sitting upright during meals and assist with eating and meal set up encourage to attempt to feed self-assisting as needed. On 9/20/23 at 12:21 PM…

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 (R2) who had previously been placed on continual monitoring was monitored resulting in R2's fall. This failure affects one (R2) resident out of three residents reviewed for accidents in a sample list of nine residents. Findings include: R2's Medical Diagnosis List documents active diagnoses of Alzheimer's Disorder, Anxiety, Polyneuropathy and Dementia with other Behavioral Disturbances. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately impaired in decision making. R2's Electronic Medical Record (EMR) does not document R2's fall on 8/29/23. This same medical record does not document R2's skin assessment, neurological assessment, or Post Fall Evaluation for R2's fall on 8/29/23. R2's Care Plan documents an intervention revised 8/24/23 for R2 to use one person assist for all transfers. This same care plan instructs staff to monitor whereabouts of R2. R2's Physician Order Sheet (POS) dated September 2023 documents a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete pressure ulcer risk assessments for (R3), monitor and assess pressure ulcers for (R3), document skin assessments as ordered for (R3) and implement pressure relieving interventions for (R1 and R3). R1 and R3 are two of three residents reviewed for pressure ulcers in the sample list of 88. Findings include: 1.) R3's Diagnoses List dated 9/7/23 documents R3's diagnoses include Cerebral Infarction, Diabetes Mellitus Type 2, Protein-Calorie Malnutrition, and gastrostomy tube status. R3's Minimum Data Set, dated [DATE] documents R3 has cognitive impairment, requires extensive assistance of at least two staff, is always incontinent of bowel and bladder, and R3 is at risk for pressure ulcers. The only Braden Assessment documented in R3's electronic medical record is dated 5/3/23 and documents a score of 12, indicating R3 is at high risk for developing pressure ulcers. R3's Physician Order dated 8/13/23 documents to use an air mattress.…

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 repeatedly to ensure gastrostomy tube (G-tube) feeding volumes were administered as ordered for (R2 and R3), failed to record the amount of feeding administered for (R2 and R3), and failed to verify gastrostomy tube placement prior to administering feeding and medications for (R1). These failures affect three of three residents (R1, R2, and R3) reviewed for gastrostomy tubes on the sample list of 88. Findings include: 1.) R3's Physician Order dated 7/3/23 documents an order for Glucerna 1.2 at 65 cc (cubic centimeters) on at 4:00 PM and off at 12:00 PM. This order does not document the total volume to be infused. R3's Nutrition Note dated 08/31/2023 recorded by V24 Dietitian documents R3 receives nothing by mouth and receives full tube feedings via gastrostomy tube. R3's tube feeding regimen is Glucerna 1.2 at 65 ml/hour for 20 hours to provide 1300 ml of feeding, 1560 kilocalories, 78 grams of protein, which is 100 % of the recommended…

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 resident bedroom, bathroom and shower room call lights in operable condition on the second floor of the facility. This failure affects 84 of 84 residents (R1-R3, and R8-R88) reviewed for call lights on the sample list of 88. The findings include: On 9/7/23 at 4:35 pm R43 was standing next to R43's bed. A hand-held call bell sat on R43's bedside table. R43 stated I am (expletive). It has been way to long waiting for the call lights to get fixed. The CNA's (Certified Nursing Assistants) only hear the bells if they are right outside the door, in the hall. We need something that goes off at the nurse's station. I flag people at the nurse's station when the CNAs don't get to me using the bell. On 9/7/23 at 4:38 pm R44 was laying in bed with a hand-held call bell on the bedside table. R44 stated I have to agree with (R43) it takes too long for staff to respond, unless they are just outside the door. On 9/7/23 at 4:41 pm R10, R51, R52, and R53 all had handheld bells on the side tables of their shared room.…

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 Family Member and provide a written Notice of Transfer and Discharge from the facility, when being discharged to the hospital. This failure affects one of three residents (R1) reviewed for discharge from the facility. This past non-compliance occurred from 8/15/23 to 9/1/23. Findings include: R1's Minimum Data Set, dated [DATE] documents R1 has severe cognitive impairment. On 9/5/23 at 4:00 pm, V6, (R1's Power of Attorney/Family Member) stated the facility failed to notify V6 by phone and in writing, that R1 was transferred to the hospital on 8/15/23. V6 stated V6 found out R1 was transferred to the hospital, when V6 received a phone call, from a staff member, at a local hospital. R1's Health Status Note dated 08/15/2023 at 01:42 am, signed by V39, Agency Registered Nurse, documents the following: Note Text: Resident is warm to touch. Lethargic and none verbal. Responds to hard sternal rub with slight eye opening. Sweating. VS (vital…

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 pressure ulcer risk assessments, wound assessments, and wound physician progress notes were part of the electronic medical record for one of five residents (R3) reviewed for pressure ulcers in the sample list of 88. Findings include: R3's Care Plan documents R3 admitted to the facility on [DATE]. The only Braden Assessment documented in R3's electronic medical record is dated 5/3/23 and documents a score of 12, indicating R3 is at high risk for developing pressure ulcers. R3's August 2023 Treatment Administration Record (TAR) documents on 7/27/23 an order for a bordered foam gauze dressing to the right buttock was implemented as a preventative. On 8/13/23 an order was initiated to cleanse the right buttock and coccyx, apply medicated honey, and cover with a foam dressing daily. R3's Nursing Notes document on 8/13/23 R3 had three new open pressure wounds. Two to the right buttock that measured 1.5 centimeters (cm) by 2 cm and 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.