Shelbyville Healthcare & Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the dignity of one (R1) resident out of five residents reviewed for resident rights in a sample list of five residents. Findings include: The undated facility pamphlet titled Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long Term Care Facilities documents the facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. R1's undated Face Sheet documents admitted to the facility on [DATE] and lists R1's medical diagnoses as Lymphedema, Chronic Venous Hypertension with ulcer of lower extremity, Diabetes Mellitus Type II, Parkinson's Disease, Cellulitis of Right and Left Lower Limbs, Morbid Obesity, Chronic Kidney Disease Stage 3, Acute Kidney Failure and Chronic Congestive Heart Failure. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. This same MDS documents R1 as requiring supervision with bathing and putting on and removing footwear.…

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 residents were treated with dignity for two (R2, R3) residents out of three residents reviewed for abuse in a sample list of six residents. Findings include: The Illinois Long Term Care Ombudsman Program pamphlet titled Resident Rights for People in Long Term Care Facilities revised November 2018 documents the facility must treat the resident with dignity and respect and must care for the resident in a manner that promotes the residents' quality of life. R2 and R3's shared Final Report to the State Agency dated 2/18/25 documents R2 and R3 reported that at times V13 (Licensed Practical Nurse/LPN) could be short with her responses but denied that she was mentally or verbally abusive to (R2, R3). R2 and R3's shared abuse investigation documents V13 (LPN) was in-serviced on 2/17/25 on Tone of voice when responding to residents' customer service, communication, and interacting with residents during medication pass. 1. R2's Minimum Data Set (MDS) 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 ensure the safety of one (R1) resident from physical abuse by a staff member out of three residents reviewed for abuse in a sample list of six residents. Findings include: R1's undated Face Sheet documents medical diagnoses as Dementia, Psychotic Disorder with Hallucinations, Muscle Weakness, Unsteady on Feet, Reduced Mobility, Restless and Agitation and Violent Behavior. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 as independent in toileting, dressing, personal hygiene, bed mobility, moving from a sitting to standing position and able to self-propel her wheelchair 150 feet. R1's AIM for Wellness dated 1/29/25 documents R1 had an alleged unintentional change in plane and an altercation with a staff member (V3) Certified Nursing Assistant/CNA. This same report documents (R1) was arguing with (R5) and (V3) CNA. (R1) was also upset with (V3) CNA when V3 CNA tried to redirect and take…

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 a concern voiced in Resident Council Meeting of a staff members poor demeanor towards two (R2, R3) residents out of three residents reviewed for abuse in a sample list of six residents. Findings include: The facility policy titled Abuse Prevention Program revised May 2021 documents Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriate of resident property they observe, hear about, or suspect to a supervisor and the Administrator. Upon learning of the report, the Administrator or designee shall initiate an investigation. The facility Resident Council Minutes dated 1/22/25 document resident concerns of night nurse (V13) Licensed Practical Nurse (LPN) demeanor towards residents. These same minutes document V12 (Previous Activity Director) as the staff liaison for this resident council meeting. On 2/14/25 at 2:10 PM R2 stated V13's 'poor demeanor' was discussed in January's Resident Council meeting. R2 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 provide Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 10 days in a total of 39 days reviewed. This failure affects 25 residents residing in the facility. Findings include: The Long-Term Facility Application for Medicare and Medicaid form CMS 671 dated August 7, 2024 documents the census for the facility as 25 residents. Reviewing the facility's nurse assignment sheets for the months of July and August 2024. The facility had 10 days out of the 39 days reviewed which did not document RN time of 8 hours per day. The facility did not have a RN working at least 8 consecutive hours a day on 7/6/24, 7/7/24, 7/13/24, 7/14/24, 7/20/24, 7/21/24,7/27/24, 7/28/24, 8/3/24 and 8/4/24. V2 (Director of Nurses) confirmed on 8/8/24 at 12pm, Yes, this is correct we do not have the RN coverage for the weekends.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to honor the resident's right to formulate advanced directives. This failure affects one resident (R179) out of 16 reviewed for advanced directives on the sample list of 28. Findings include: On [DATE] at 1:57 PM, R179's Electronic Medical Record did not include any information about R179's wishes or election of advanced directives (code status). This same record documents R179 was admitted to the facility on [DATE]. On [DATE] at 2:00 PM, R179 stated, No, no, no, I would not like to be resuscitated. R179 continued, I don't think I am being selfish about it; I am just in pain all the time and I wouldn't want to be brought back for that. R179's Face Sheet dated [DATE] documents R179 is his own responsible party. On [DATE] at 2:10 PM, V3 (Licensed Practical Nurse) looked through R179's Electronic Medical Record, as well as R179's paper chart, and stated, I don't see anything signed as DNR (Do Not Resuscitate) so he would be treated as a full code (all…

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 promote resident's right to a safe, comfortable homelike environment. This failure affects one of two residents (R14) reviewed for the environment on the sample of 28. Findings include: R14's Minimum Data Set, dated [DATE] documents the following: R14's Brief Interview of Mental Status score as 14 out of a possible 15, which indicates no cognitive impairment. On 08/06/24 at 10:05 am, R14 was lying in bed. Between the head of R14's bed and R14's bedside dresser there was an unpainted, 10-inch hole. The hole had loose, crumbling white plaster-like substance. R14 stated I have gotten use to looking at that. It is not pretty. The hole in the wall has been there since I came to the facility, two years ago. It could use some attention. On 8/7/24 at 11:15 am, during a resident group meeting, R14 stated I told you yesterday about the hole in my wall. You saw it. It is terrible. I set on the side of my bed and eat. I can't help but see it. You…

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 R14's Bilevel positive airway pressure (Bi-PAP) mask was replaced in a timely manner which resulted in facial skin breakdown. This failure affected one of one resident (R14) reviewed for the respiratory medical equipment on the sample list of 28. Findings include: R14's Current Physician Order Summary Sheet documents the following: BiPAP wear nightly. Observe resident every four hours while in use. Cleanse mask as needed after each use every shift related to Chronic Obstructive Pulmonary Disease (COPD) Unspecified. R14's Minimum Data Set, dated [DATE] documents the following: R14's Brief Interview of Mental Status score as 14 out of a possible 15, which indicates R14 has no cognitive impairment. R14's Care Plan dated 8/04/24 documents the following: Resident has a potential impairment related to fragile skin. The resident will maintain or develop clean and intact skin by the review date. Educate resident/family/caregivers of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement a resident's departure alert system safety bracelet intervention, for twelve days after a resident's elopement. This failure affects one of four residents (R129) reviewed for incident /accidents on the sample list of 28. Findings include: R129's admission Diagnoses Sheet dated 7/24/24 documents the following: Altered Mental Status, Unspecified, Other Abnormalities of Gait and Mobility, Unspecified Lack of Coordination. Unsteady On Feet, and Other Malaise. R129's Admission, Elopement Risk Assessments dated 7/24/24 documents R129 is at high risk of elopement, has a history of elopement from home, is ambulatory, cannot communicate and wanders into other resident rooms. R129's Minimum Data Set (MDS) dated [DATE] documents R129 has a Brief Interview of Mental Status Score of 00 out of a possible 15, which indicates severe cognitive impairment. The same MDS documents R129 has had wandering behaviors 1-3 days during the seven day look…

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 timely infection control precautions for a resident positive with bacteria in the urine, provide Personal Protective Equipment (PPE) to ensure effective infection control when caring for residents, provide designated trash receptacles in resident room, ensure staff wore appropriate PPE during direct care, and implement a room change for a resident to prevent potential cross contamination. These repeated failures were ongoing 08/04/24-08/06/24. These failures affected two of two residents (R7 and R19) reviewed for infection control on the sample list of 28. Findings include: On 08/06/24 between 10:00 and 11:00 am, R7 and R19 had a sign posted on their bedroom door that stated enhanced barrier precautions. There was no signage for contact isolation precaution. There were no PPE (Personal Protective Equipment) supplies set up of outside R7 and R19's room. There were no designated receptacles in R7 and R19's room for discarding soiled…

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 a Registered Nurse (RN) at least eight consecutive hours a day. This failure has the potential to affect all 24 residents residing in facility. Findings include: The Daily Census dated 3/20/24 documents 24 residents reside in facility. The Facility Daily Staffing Sheets dated 3/2/24, 3/3/24, 3/9/24, 3/10/24, 3/16/24 and 3/17/24 does not document an RN on duty. The Facility Assessment updated 1/9/24 documents the facility will provide a Registered Nurse (RN) at least eight hours per day. On 3/20/24 at 3:45 PM V2 (Director of Nurses) stated the facility does not have adequate Registered Nurse (RN) coverage. V2 stated We (facility) do not have any RN coverage on the weekends. I am hiring but having trouble finding RNs to work the weekends. I work Monday-Friday only. I am on call on the weekends, but I am not in the building for eight hours. I might come in for a few minutes here and there but not for the whole eight hours.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide rehabilitation services to four (R1, R2, R3, R4) residents out of four residents reviewed for Rehabilitation Services in a sample list of four residents. Findings include: The Facility Daily Census dated 3/20/24 documents 24 residents reside in facility. The Facility Assessment updated 1/9/2024 documents the facility will provide therapy services including Physical Therapy (PT), Speech Therapy (ST) and Occupational Therapy (OT). On 3/20/24 at 3:45 PM V1 (Administrator) stated The previous therapy company gave our facility five days' notice that they were leaving. Their last day was 2/18/24. We (facility) have not had any therapy services since 2/18/24. We (facility) have been working diligently on regaining therapy services from another therapy company. We have not admitted any new residents but those that are involved have not received any therapy. 1.) R1's undated Face Sheet documents R1 admitted to facility on 2/22/2023. R1'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 provide the services of a Registered Nurse for eight consecutive hours seven days a week for 11 of 14 days reviewed. This failure has the potential to affect all 34 residents residing in the facility. Findings Include: The facility's Nurse Staffing policy with a review date of 12/7/17 documents, It is the policy of (the facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical, physical, mental, and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and the Director of Nursing as specified by the Illinois Department of Public Health. On 7/16/23 at 7:55 AM, V4 (Licensed Practical Nurse/LPN) stated that V4 was the only nurse working in the building at that time. The facility's nursing daily working schedules from 7/1/23 through 7/14/23 document the facility did not have the services of a Registered Nurse (RN) for eight consecutive hours on 7/2/23, 7/3/23, 7/4/23, 7/5/23, 7/6/23,…

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 prevent cross contamination during meal service in a sample list of 34 residents. This failure has the potential to affect all 34 residents residing in facility. Findings include: The Daily Census Midnight Report dated 7/16/23 documents 34 residents residing in facility. On 7/16/23 at 12:00 PM, V13 (Head Cook) applied gloves to plate lunch meal. V13 rubbed V13's temple area on face two separate times while wearing serving gloves. V13 then used same contaminated gloves to serve meals. V13 (Head Cook) wore same contaminated gloves to adjust V13's glasses one time, then a separate time, V13 used same contaminated gloves to remove glasses. V13 picked up a meal card from the floor, removed gloves, and used the sink sprayer to rinse the tips of V13's fingers on Left hand for less than two seconds. V13 did not use hand hygiene during meal service after contaminating serving utensils used to plate resident meals. On 7/16/23 at 12:45 PM, V13 (Head Cook) stated, I can't believe I even did that. I know better than to…

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

Based on interview and record review the facility failed to have the required members attend the Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential to affect all 34 residents residing in the facility. Findings include: On 7/17/23 at 9:30 AM, the QAPI Quarterly Meeting sign in sheets provided by V1 (Administrator) documents the Quarter 4 of 2022 meeting dated 10/4/22 sign in sheet did not have a Director of Nursing in attendance, the Quarter 1 of 2023 meeting dated 1/3/23 sign in sheet did not have a Director of Nursing in attendance, and the Quarter 2 of 2023 meeting dated 4/4/23 sign in sheet did not have a Director of Nursing in attendance. On 7/17/23 at 9:35 AM, V1 (Administrator) confirmed that they did not have a Director of Nursing (DON) at those meetings. V1 stated that they just hired a DON in May, and they went a long time without one. The facility's Resident Census and Conditions of Residents report dated 7/16/23 documents 34 residents reside in the facility.

Based on observation, interview and record review, the facility failed to provide bedrooms that measure at least 80 square feet per resident bed. This failure affects 34 out of 34 residents all of whom occupy Medicare or Medicaid certified beds in the facility. Findings include: The facility Daily Midnight Census Report dated 7/16/23 documents 34 residents reside in facility. The undated Centers for Medicare and Medicaid Services Certification and Transmittal, documents 80 of the facility's 80 beds are certified Title 18 (Medicare) and/or Title 19 (Medicaid). Rooms 402-407 are double occupancy and dually certified for Medicare and Medicaid, while rooms 101-112, 201-210, 300-311 and 401 are double occupancy and certified for Medicaid. On 7/17/23 at 1:30 PM, observed V8 (Maintenance Director) measure a resident room. Room measured 72.5 square feet per resident bed in a double occupancy room. Observed R33's room to contain two twin beds, two dressers, one recliner chair, a double-sized closet and privacy curtain to separate beds. On 7/17/23 at 2:00 PM, R33 stated, My room is fine 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 have comprehensive care plans for four of twelve residents (R5, R8, R15, R19) reviewed for care plans in the sample list of 23. Findings include: 1.) R5's Order Summary dated 7/16/23 documents diagnoses including Metabolic Encephalopathy, Cerebral Infarction, Dementia, Repeated Falls, Muscle Wasting and Atrophy, Muscle Weakness, Need for Assistance with Personal Care, Difficulty in Walking, Unsteadiness on Feet, Cognitive Communication Deficit and Unspecified Dementia with Agitation. This Order Summary documents R5 was admitted on [DATE]. The facility's Fall Analysis Log provided on 7/16/23 documents R5 had a fall on 6/29/23 where R5 slid off the footrest of the recliner and on 7/12/23 where R5 attempted an unsafe transfer. R5's Baseline Care Plan dated 6/5/23 does not document any risk for falling or any interventions to prevent falls. R5's Bed Rail/Transfer Bar Evaluation dated 6/5/23 documents R5 has a history of falls. R5's Care Plan…

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 psychotropic medication assessments, implement/evaluate resident centered interventions, and identify and track targeted behaviors for four of six residents (R19, R12, R9 and R18) reviewed for psychotropic medications in a sample list of 23 residents. Findings include: 1. R19's Medication Administration Record (MAR) for July, 1.2023 to July 31,2023 include orders for: 1. CLONAZEPAM (antianxiety) 0.5 Milligram Give 1 tablet orally at bedtime 2. QUETIAPINE (antipsychotic) 25 MG TAB Give 1 tablet orally at bedtime. 3. TRAZODONE (anti-depressant) 150 MG TABLET Give 2 tablet orally at bedtime. 4. VENLAFAXINE ER (antidepressant) 150 MG Capsules Give 1 capsule orally two times a day. R19's Psychotropic Medication Quarterly evaluations are dated 8/26/22, 11/22/22, and 5/25/23. Therefore, they are not done on a quarterly basis. There is no documented psychotropic assessment for R19's Venlafaxine ER. There are no resident specific targeted behaviors being tracked. No nonpharmacological interventions are documented. 2. R12'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 complete Psychotropic Medication consent forms for three (R9, R18, R33) out of five residents reviewed for unnecessary medications in a sample list of 23 residents. Findings include: 1.) R9's Medical Record documents medical diagnoses of Depression, Anxiety and Bipolar disorder. R9's Physician Order Sheet (POS) dated June 2023 documents a physician order dated 6/27/23 for Trazadone 25 mg every 24 hours as needed. This same POS documents a physician order for Divalproex Sodium Extended Release (ER) 500 mg every bedtime. R9's undated Psychotropic Medication Consent form documents R9's Trazadone (antidepressant, sedative) 25 milligrams (mg) daily at bedtime was changed to As Needed. This same document does not document benefits to R9, nor date consent was signed, nor witness to signing of consent. R9's undated Psychotropic Medication Consent form for Divalproex Sodium 500 mg every bedtime does not include a witness signature. On 7/17/23 at 1:40 PM, R9 stated I take some meds for my condition. They (medications) help me. They…

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 resident centered fall interventions and failed to completely investigate falls/determine root cause for one of five residents (R5) reviewed for falls in a sample list of 23. Findings include: 1.) R5's Order Summary dated 7/16/23 documents diagnoses including Metabolic Encephalopathy, Cerebral Infarction, Dementia, Repeated Falls, Muscle Wasting and Atrophy, Muscle Weakness, Need for Assistance with Personal Care, Difficulty in Walking, Unsteadiness on Feet, Cognitive Communication Deficit and Unspecified Dementia with Agitation. This Order Summary documents R8 was admitted on [DATE]. R5's Minimum Data Set (MDS) dated [DATE] documents R5 requires extensive assistance of two staff for transfers and limited assistance of one staff member for ambulating in R5's room. R5's Fall Investigation dated 6/29/23 at 6:00 AM documents, Incident Description: (R5) laying on floor on left side. Lift chair beside (R5) with leg rest up. (R5) states…

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

Based on observation, interview, and record review the facility failed to administer oxygen at the correct setting for one of two residents (R8) reviewed for oxygen administration in the sample list of 23. Findings include: The facility's Oxygen Therapy policy with a reviewed date of March, 2019 documents, Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Procedure: 1. Verify physician's order. 8. Adjust delivery rate per the physician's order. R8's Order Summary dated 7/16/23 documents diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Cerebral Infarction, Hypertension and Presence of Cardiac Pacemaker. This Order Summary documents an order for oxygen at 2 - 5 liter per minute per nasal cannula continuously every day and night shift with a start date of 2/1/23. On 7/16/23 at 9:21 AM, R8 is in R8's bed and has oxygen on via a nasal cannula and the oxygen concentrator is on and set at 1.5 liters per minute. On 7/17/23 at 9:46 AM, R8 is in R8's bed and R8's oxygen concentrator is set at 1.5 liters per…

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 prevent cross contamination during pressure ulcer dressing change for one (R186) resident of two residents reviewed for pressure ulcers. Findings include: R186's Medical Diagnosis list documents a diagnosis of Stage 4 Sacral Pressure Ulcer. R186's Minimum Data Set (MDS) dated [DATE] documents R186 as moderately cognitively impaired. This same MDS documents R186 as requiring extensive assistance of two people for bed mobility, transfers, dressing, toileting, and extensive assistance of one person for personal hygiene. R186's Physician Order Sheet (POS) dated July 2023 documents a physician order for Eravacycline Dihydrochloride Intravenous Solution Reconstituted 50 milligrams (mg) every 12 hours for wound infection. This same POS documents a physician order for Linezolid Oral Tablet 600 MG twice daily for Stage 4 Sacral Pressure Ulcer infection. On 7/17/23 at 2:20 PM, V4 (Licensed Practical Nurse/LPN) completed R186's Stage 4 Sacral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their Antibiotic Stewardship policy for one of two (R19) residents reviewed for Antibiotic Stewardship in a sample list of 23. Findings include: The facility policy titled 'Antibiotic Stewardship Program' reviewed 3/20/23 documents the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This same policy instructs staff to determine whether the resident's documented signs and symptoms align with the recommended minimum criteria for initiating antibiotics. This same policy instructs staff to determine whether the infection met the criteria for Centers for Disease Control and Prevention (CDC) standard definitions for infection surveillance in long term care. R19's diagnoses list printed 7/19/23 at 9:31AM includes the following diagnoses: Chronic…

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.