Accolade Healthcare Of Savoy

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.

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.

Based on interview and record review, the facility failed to address/provide response for concerns voiced during resident council meetings. These failures have the potential to affect all 122 residents residing in the facility. Findings include: The facility's Resident Council meeting minutes document resident concerns as follows: 1/18/22 10:30 AM Residents are concerned about food and consistently needing to discuss the food preparations. Residents would like more crunchy foods and more food choices at lunch and dinner. Residents are concerned with the internet and phone situations that were addressed over the holiday season. Residents concerned with shower times. 2/15/22 10:30 AM Residents concerned about the food, consistently. Food preparations needing revisited with the residents. Residents would like more variety in their foods for all meals. Residents concerned with medication pass and shower times. 3/8/22 at 10:30 AM Residents are concerned about the mealtimes and food preparations. Residents would like more variety in their foods for all meals. Residents are concerned about…

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

Based on observation, interview and record review the facility failed to provide a full time Director of Nursing (DON) since January 1, 2022. These failures have the potential to affect all 122 residents in the facility. Findings include: On 8/29/22 there was no Director of Nursing at the facility. On 8/31/22 at 1:10 PM V3 Infection Control Nurse stated that there had not been a director of nursing in months. On 9/6/22 at 11:00 AM, V30 Wound Nurse stated, We haven't had a Director of Nursing in 8 months and that isn't helping us. On 9/8/22 at 10:00 AM, V21 Care Plan Coordinator stated that she did not work as a Director of Nursing forty hours per week at any time. The facility's August 2022 Nursing schedule does not document a Registered Nurse (RN) on the schedule at any time. The facility's Resident Census and Conditions of Residents form dated 8/29/22 documents 122 residents reside in the building.

Based on observation, interview, and record review, the facility failed to maintain sanitary food preparation and storage areas. These failures have the potential to affect all 122 residents in the facility. Findings include: On 8/29/22 at 10:00 AM, Four rolling storage bins were located under a counter in the kitchen. These bins contained oatmeal, sugar, flour, and breadcrumbs. The clear plastic openings on the top of the bins and the sides of these bins were covered with spots of various sticky residue and were streaked with dirt. At that time, V18 Certified Dietary Manager stated that they push these bins to the preparation and cooking areas and that is how they get soiled. V18 stated that these bins needed cleaned. On 8/29/22 at 10:10 AM, A drawer connected to the underneath of a small food preparation area containing potholders and loose papers had spilled dried puddles of liquids. A three-compartment container containing ladles and scoops had accumulated crumbs and dried spilled areas inside the container where the ladles and scoops were lying. Three clear plastic containers…

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 designate and operationalize an effective governing body, impacting the operations of the facility. This failure had the potential to affect all 122 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] through 5/1/23 documents V13 (Former Administrator) as the Administrator and the Governing Body of the facility. This assessment does not document who the Administrator reports to concerning the management and operation of the facility. On 9/8/22 at 1:44 PM, V2 [NAME] President of Clinical and Reimbursement stated V2 is not sure who the governing body of the facility is and that she is over nursing only. V2 stated she does not oversee the Administrator or her duties in the facility. V2 stated the Administrator completed the facility's Facility Assessment. V2 stated the facility's Facility Assessment is not accurate as the Administrator cannot also be the governing body. The facility's Census and Condition…

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 implement a quality assurance program within the facility. This failure has the potential to affect all 122 residents residing in the facility. Findings include: On 9/1/22 at 11:06 AM V1 Administrator stated, I cannot say that (we) have quality projects or a quality assurance performance improvement program. On 9/7/22 at 2:30P M, V1 Administrator provided quality meeting sign in sheets for 3/25/22, 5/27/22 and 7/22/22. V1 Administrator confirmed that these were the only documented quality meeting sign in sheets that could be found. The facility Quality Assessment and Assurance Plan dated November 2017 documents, The facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assessment and Assurance Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality and resolve identified problems. The resident census and condition report dated 8/29/22 documents 122 residents residing in the facility.

Based on interview and record review the facility failed to hold quarterly quality meetings. This failure has the potential to affect all 122 residents residing in the facility. Findings include: On 9/1/22 at 11:06 AM V1 Administrator stated, (The facility) didn't have quarterly quality meetings. On 9/1/22 at 11:06 AM V1 Administrator stated, I cannot say that (we) have quality projects or a quality assurance performance improvement program. On 9/7/22 at 2:30PM, V1 Administrator provided quality meeting sign in sheets for 3/25/22, 5/27/22 and 7/22/22. V1 Administrator confirmed that these were the only documented quality meeting sign in sheets that could be found. The facility Quality Assessment and Assurance Plan dated November 2017 documents, This committee shall meet quarterly to review reports, evaluate the significance of data and monitor quality-related activities of all departments, services or committees. The resident census and condition report dated 8/29/22 documents 122 residents residing in the facility.

Based on interview and record review the facility failed to include the Director of Nursing in quality assurance meetings. This failure has the potential to affect all 122 residents residing in the facility. Findings include: On 9/1/22 at 11:06 AM V1 Administrator stated that the only meetings that could be found were in March, May and June of 2022 and there was no Director of Nursing at the time. On 9/7/22 at 2:30 PM, V1 Administrator provided quality meeting sign in sheets for 3/25/22, 5/27/22 and 7/22/22 none of the sign in sheets include a Director of Nursing in attendance. V1 Administrator confirmed that these were the only documented quality meeting sign in sheets that could be found. The resident census and condition report dated 8/29/22 documents 122 residents residing in the facility.

Based on observation, interview, and record review the facility failed to ensure a licensed nurse was vaccinated for COVID-19. This failure has the potential to affect all 122 residents residing in the facility. Findings include: The Vaccination of Facility Staff policy dated as revised 2/23/22 documents: If required, second dose administration shall be received per vaccination requirements, and evidence of this second vaccination shall be submitted for copy into the employee's personnel file and recorded on the Employee Vaccination Roster. Employees failing to obtain the required second vaccination dose per CDC (Centers for Disease Control and Prevention) guidelines shall be removed from the schedule and placed on unpaid administrative leave until meeting this requirement. Failure to meet this requirement within two weeks of this unpaid administrative leave shall be considered a voluntary resignation. The CDC's Stay Up to Date with COVID-19 Vaccines Including Boosters guidance dated 9/8/22 documents the 2nd primary dose of a twostep series should be given 3-8 weeks after the 1st…

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 promote residents' dignity by failing to ensure residents were served meals at the same time, ensure staff did not stand over residents while providing feeding assistance, ensure staff did not enter without knocking before entering a resident's bathroom, ensure staff provide assistance with dressing and shaving, and ensure staff removed institutional identification (hospital bracelets) and gait belts for 12 (R56, R42, R70, R92, R50, R86, R47, R104, R96, R91, R215, R14) of 24 residents reviewed for dignity in the sample list of 99. Findings include: The facility's undated Resident Rights, Privacy and Dignity policy documents: The resident has the right to be treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility may encourage and assist the residents to dress in their own clothes, rather than hospital type gown and appropriate footwear for the time of the day and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to keep residents' emergency nurse call light devices within reach (R3, R36 and R371) and failed to provide a call light device that was appropriate for resident capability (R100), in four of 24 residents reviewed for call lights in a total sample list of 99. Findings include: The facility Use of Call Light policy dated October 2010 documents, The purpose of the call light procedure is to respond to the residents' request and needs. 3) Ask the resident to return the demonstration so that you will be sure that the resident can operate the system. 6) When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. 1) On 8/29/22 at 10:00 AM, R3's call light device was laying on the floor out of reach of R3. R3 stated, I don't know where it is. I hurt! 2) On 8/29/22 at 10:36 AM, R36 was lying in bed while R36's call light device was tied across the room. R36 could not access the call light across 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 protect R52, R64, R89, and R99 from potential/further abuse pending investigation, following witnessed instances of physical, sexual, and mental/verbal abuse by R46 and V31. These failures impact six of seven residents (R46, R52, R64, R89, R95, R99) reviewed for abuse in the sample list of 99. Findings include: The facility's abuse policy documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; VI. Protection of Residents. The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a Comprehensive Care Plan for falls, bilateral hearing aide use, nutrition, weight loss and anticoagulant medication use for four of 24 residents (R74, R21, R101, R70) reviewed for Care Plans in the sample list of 99. Findings include: The facility's Care Plans-Comprehensive policy with a revised date of 1/2011 documents, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. A comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum…

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 update resident Care Plans with falls, nutrition and weight loss concerns. The facility failed to conduct a Care Plan meeting with a resident's family and failed to invite a resident to the resident's Care Plan meeting for four of 24 residents (R74, R100, R95, R13) reviewed for Care Plans in the sample list of 99. Findings include: The facility's Care Plans-Comprehensive policy with a revised date of 1/2011 documents, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 7. The resident's comprehensive care plan is developed…

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 3.) R215's hospital summary dated 8/20/22 documents R215 has a history of Congestive Heart Failure. R215's physician order dated 8/24/22 documents to obtain daily weights. Notify physician if weight gain of more than 3 lbs per day or more than 5 lbs in one week. R215's medical record does not document weights were done daily. R215's medical record from 8/24/22 to 9/8/22 daily weights were only completed on 8/30/22, 9/2/22, and 9/6/22. R215's Wound Evaluation Form documented by V46 Wound Physician documents R215 has a Diabetic wound to the right ankle. This form includes a recommendation for a calf high heel protector while in bed. On 8/31/22 at 11:28 AM, R215 was lying in bed on his right side. R215's legs were curled up and R215's feet were crossed. R215 was not wearing a calf high heel protector or any other type of heel protector. At that time, a calf high heel protector was lying on a three-drawer cabinet on the other side of the room. On 8/31/22 at 11:45 AM, V35 Licensed Practical Nurse stated she was…

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

Based on observation, interview, and record review the facility failed to provide meals that met dietary needs and preferences for four (R14, R215, R106, and R214) of 24 residents reviewed for meals on the sample list of 99. Findings include: 1. On 8/29/22 at 11:11 AM, R14 stated he is supposed to get double portions but does not get his double portions. R14's lunch ticket on the tray documented R14 was to receive double portions. On 8/31/22 at 11:31 AM, R14 received a lunch tray. R14 stated, See, I didn't get double portions. R14's tray had one serving of roast beef, one scoop of potatoes, one scoop of cauliflower, one piece of bread and one bowl of fruit. On 8/31/22 at 11:40 AM, V35 Licensed Practical Nurse stated R14 is supposed to receive double portions, but the kitchen never sends him double portions. V35 stated it is a constant problem and that sometimes she will call and tell them they didn't send them, and they tell me they are out or will bring some but half the time they never show up with the double portions. 2. On 8/31/22 at 11:57 AM, R215 was served a piece of roast…

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 prepare and serve meat that was easily cut and chewed for five (R214, R113, R67, R70, and R13) of 24 residents reviewed for meals on the sample list of 99. Findings include: 1. On 8/31/22 at 11:30 AM, R214 was eating lunch in her room. R214 stated her lunch had a good flavor but the roast beef was tough, and she could hardly chew it. R214 was picking at the roast beef, and it appeared dry and leathery. 2. On 8/31/22 at 12:14 PM, V12 Certified Nursing Assistant was assisting R113 with her meal in her room. V12 couldn't hardly cut the meat with the butter knife sawing back and forth R113's meat. On 8/31/22 at 12:17 PM, V12 Certified Nursing Assistant was picking up the lunch trays from the resident rooms. V12 stated it's all been hard to cut. V12 took a piece of meat off a tray that someone did not eat and had to pull hard to pull it apart. 3. On 8/3/22 at 12:15 PM, R67 was standing up at her bedside table eating her lunch. R67 stated the roast beef was tough and was ripping it apart to eat it. 4. On 8/31/22 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.

Based on observation, interview, and record review the facility failed to disinfect scissors after a wound treatment, change gloves, perform hand hygiene during incontinence care, implement isolation signage, isolation laundry, waste bins for transmission-based precautions, and ensure staff properly wear Personal Protective Equipment (PPE). These failures have the potential to affect for five (R13, R70, R82, R91, R103) of 24 residents reviewed for infection control in the sample list of 99. Findings include: 1.) R13's Right 5th Toe Wound Culture dated 7/24/22 documents a moderate colony count of Proteus Mirabilis (bacteria) and Methicillin Resistant Staphylococcus Aureus (MRSA, a multidrug resistant organism), indicating an active infection. R13's Order Summary Report dated 8/31/22 documents an order for contact isolation for six weeks that was initiated on 7/25/22. On 8/29/22 at 10:16 AM there was a sign posted on R13's door indicating R13 was on contact precautions. There was a cart containing PPE located outside of R13's doorway, and isolation bins for linen and waste were in…

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

Based on observation, interview, and record review the facility failed to ensure medications were consumed during medication administration for one of one resident (R215) reviewed for self-administration of medication on the sample list of 99. Finding include: On 8/30/22 at 10:45 AM, a medication cup full of medications was sitting on R215's bed side table. R215 was sitting up at the table watching television. When asked if the medication in the cup were his morning medications, R215 stated, I guess, I don't know. R215 then picked up the medications and took them. At that time, V35 Licensed Practical Nurse was at the nurses' station and stated she sat a cup of medications on his bed side table earlier and that the medications in the cup were his morning medications. V35 stated she left them for him to take. V35 stated inside the cup was Baby Aspirin, Furosemide, Lisinopril, Magnesium, Metoprolol, Multivitamin, Pantoprazole, Senna, and Spironolactone. R215's Medication Administration Record dated 8/1/22 through 8/31/22 documents R215 is to receive the following medications at 9:00…

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 the resident's physician and family of significant weight loss for three (R13, R70, R95) of twelve residents reviewed for nutrition in the sample list of 99. Findings include: The facility's Change in a Resident's Condition or Status policy with a revised date of December 2016, documents the facility will promptly notify the resident, resident's physician, and resident's representative of changes in a resident's physical, emotional, and mental condition. 1.) R13's Minimum Data Set (MDS) dated [DATE] documents R13 has severe cognitive impairment, R13 is not on a prescribed weight loss regimen, and R13 has had a weight loss of 5% or more in one month or 10% or more in six months. R13's undated weight log documents R13's weights and identified significant weight loss as follows: 118.6 lbs. (pounds) on 4/27/22, 118.7 lbs. on 5/3/22, 109.7 lbs. on 5/9/22 (7.58 % loss), 103.6 lbs. on 5/12/22 (5.56% loss in 4 days), 103 lbs. on 5/24/22 (6.11 % loss from…

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 Preadmission Screening and Resident Review (PASARR) level II was conducted after a resident was diagnosed with Bipolar Disorder for one (R95) of five residents reviewed for PASARR in the sample list of 99. Findings include: The facility's undated policy on PASRR & OBRA (Omnibus Budget Reconciliation Act) Screening documents The facility shall follow Illinois Department of Human Services requirements for PASRR and OBRA Screenings. All residents are required to go through this screening process and copy of the screening shall be maintained in the resident's record. Only those residents who screen as appropriate for long-term facility placement shall be admitted . Resident(s) who are appropriate for long-term care placement with special needs (e.g. (example) DD (Developmental Disability) and/or serious mental health issues shall be assessed for needs and an individualized plan of care shall be developed and implemented. R95's undated census list…

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 develop an initial baseline care plan for one of 24 residents (R74) reviewed for care plans in the sample list of 99. Findings include: The facility's Care Plan Process policy dated 6/2015 documents, 2. The admitting nurse initiates the interim care plan, under Observations labeled initial Care plan. 3. The remainder of the interdisciplinary team will assess the resident within 72 hours of admission and add any issues to the initial care plan to address any immediate care needs. R74's admission Minimum Data Set (MDS) dated [DATE] documents R74 was admitted to the facility on [DATE] with diagnoses including Fractures and Other Multiple Traumas, Anemia, Unspecified Fall and history of TIA (Transient Ischemic Attack). R74's MDS documents R74 had one fall in the last month and had one fall resulting in a fracture in the last six months. R74's Care Plan does not have any fall interventions until 8/6/22 when an actual fall took place. R74's initial Fall Risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with showers, nail care, shaving and dressing for two (R70, R215) of four residents reviewed for activities of daily living in a sample list of 99. Findings include: The facility's Shower Sheets policy dated February 2022, documents shower worksheets will be completed for resident showers and resident shower refusals, and the worksheets are signed by the nurse. The facility's Care of Fingernails/Toenails policy dated as revised January 2019 documents Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. The facility's undated Quality of Life-Dignity policy documents: Residents shall be groomed as they wish to be groomed (hairy styles, nails, facial hair, etc. (etcetera). Residents shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns. 1.) On 8/29/22 at 12:05 PM R70 was sitting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to investigate fall occurrences and implement fall interventions for three of four residents (R74, R21, R17) reviewed for falls in the sample list of 99. Findings include: The facility's Falls Prevention Program policy with a revised date of 11/2017 documents, Fall prevention program will be implemented to ensure all resident's safety in the facility whenever possible. This program should include a measure that determines each resident's needs by assessing the risks for falls and implementing appropriate interventions to provide the necessary supervision, and assistive devices are utilized as necessary. Post Fall Incidents: 4. Identify the root causes of the fall incident, which could be related to the resident's current or declining medical condition or worsening behavior. 5. The staff will evaluate, and document falls that occur while the individual is in the facility, for example, when and where they happen, any observations of the events,…

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 physician's orders for a urinary catheter, failed to develop and implement a plan of care related to the urinary catheter use. This failure affects one of four residents (R101) reviewed for urinary catheter use on the sample list of 99. Findings include: R101's Face Sheet documents R101 admitted to the facility on [DATE]. R101's Hospitalist Progress Note dated 7/26/22 documents R101 developed Acute Urinary Retention on 7/25/22 and a urinary catheter was placed. R101 is to follow-up with Urology as an outpatient. R101's urinary catheter was placed on 07/25/2022. (R101) will need Urology follow-up as an outpatient. This note also documents R101 is to follow-up with Urology for voiding study. R101's Post-Acute Care Transition Document dated 7/27/22 documents R101's urinary catheter as a Coude urinary catheter (slight curve near the insertion end of the urinary catheter tubing) size 14 french. This document also documents Discharge…

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

Based on observation, interview and record review, the facility failed to ensure a resident had physician's orders for use of a Continuous Positive Airway Pressure (CPAP) device. The facility also failed to ensure the resident had supplies for the device and failed to ensure the supplies were stored to prevent cross-contamination of the mask for the CPAP device, and to label Oxygen tubing and a humidification bottle. These failures affect two of two residents (R3, R21) reviewed for respiratory on the sample list of 99. Findings include: 1. R21's Order Summary Report dated 9/6/22 does not document a current physician's order for R21's Continuous Positive Airway Pressure (CPAP) device. On 08/29/22 at 12:30 PM, R21's CPAP device was observed dusty/unclean. R21's mask for R21's CPAP treatment was attached to the tubing which was attached to the machine and was in R21's dirty linen basket, uncovered. The CPAP device water reservoir compartment was dry. On 09/01/22 09:36 AM R21's Continuous Positive Airway Pressure (CPAP) device was on R21's night stand next to R21's bed. The device had…

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

Based on interview and record review, the facility failed to ensure a resident received orders for care of/maintenance for a resident's artificial eyes. This failure affects one of one resident (R101) reviewed for vision on the sample list of 99. Findings include: R101's Progress Notes dated 7/27/22 document R101 is legally blind with artificial eyes. R101's Progress Notes dated 7/27/22 at 11:56 PM document R101 is legally blind with artificial eyes. R101's Progress Notes dated 8/1/22 at 4:27 PM document R101 has artificial eyes and eye matting. R101's Baseline Care Plans are incomplete and do not include R101's bilateral artificial eye care needs. There is no documentation in R101's Care Plans dated 8/27/22 documenting a plan of care related to R101's bilateral artificial eyes and care of them. On 9/6/22 at 11:50 AM, V1, Administrator stated the facility should have contacted R101's physician to get orders/direction on how to care for R101's artificial eyes and should have a care plan in place for them.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete psychological medication assessments, complete Abnormal Involuntary Movement Scales, and to provide rationale for gradual dose reduction (GDR) refusals for one (R81) of two residents reviewed for psychotropic medications from a total sample list of 99. Findings include: R81's undated diagnoses list documents R81's diagnoses include Alzheimer's Disease, Vascular Dementia with Behavioral Disturbances, and Unspecified Psychosis. R81's Minimum Data Set, dated [DATE] documents R81 has severe cognitive impairment, R81 receives an antipsychotic medication routinely, a GDR has not been attempted and a GDR has not been documented by a physician as clinically contraindicated. R81's Order Summary Report dated 8/31/22 documents orders dated 3/6/22 for Seroquel (antipsychotic) 25 mg (milligrams) one tablet by mouth daily and two tablets by mouth daily at bedtime. R81's February 2022 Medication Administration Record documents R81 received Seroquel 25 mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications per physician's order for two of two residents (R215, R80) reviewed for significant medication errors on the sample list of 99. Findings include: 1) R215's hospital summary dated 8/20/22 documents R215 was hospitalized for Right Foot Gangrene with Cellulitis Osteomyelitis status post 4th and 5th digit amputation and followed by 2nd and 3rd metatarsal amputation with graft and Diabetes Mellitus type 2 Chronic with Neuropathy and Nephropathy. R215's Electronic Medical Record documents R215 was admitted to the facility on [DATE]. R215's physician orders documents orders dated 8/20/22 for Ertapenum Sodium 1 gram intravenously for right 4th and 5th toe amputation, Empagliflozin 20 milligrams every day for Diabetes Mellitus Type II, and Protonix (Gastric Acid Secretion Reducer) 40 milligrams every day for Gastrointestinal Reflux Disorder. R215's Medication Administration Record dated 8/1/2022 through 8/31/22 documents that R215 did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer COVID-19 (Human Coronavirus Infection) immunizations for three (R9, R99, and R31) of five residents reviewed for immunizations in the sample list of 99. Findings include: The facility's Prevention of Coronavirus (COVID-19) Infection Control Policy dated as reviewed 8/29/22 documents 4. Resident/patients will receive recommended immunization per CDC (Centers for Disease Control) recommendation. 5. Staff will obtain consent for COVID-19 vaccination from the resident or appropriate decision maker (POA (Power of Attorney)). Document the declination and approval of vaccines. 6. The physician will order the type of vaccination available. 7. Nursing staff will administer and document the COVID Vaccine as ordered when available. The facility's COVID Vaccination Log for residents dated 8/25/22 does not document that R94, R99, R31 have received any primary doses of the COVID-19 vaccine. The facility's Staff Testing Positive for COVID-19 logs dated…

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