Thryve of South Holland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for catheter care by not ensuring residents catheters were positioned properly to prevent contamination. This failure applies to two of three residents (R1 and R5) reviewed for catheter care. Findings include: 1. R1 is an [AGE] year-old male with a diagnoses history of Dementia, Parkinson's Disease without Dyskinesia, Traumatic Brain Injury, Chronic Kidney Disease, Urine Retention, Urinary Tract Infections, Dysphagia, Disorder of Muscle, and Blindness in Right Eye who was admitted to the facility 04/16/2025. R1's Current Care Plan initiated 04/17/2025 documents he has an Indwelling Catheter related to obstructive Uropathy with interventions including check tubing for kinks each shift. On 04/21/2025 at 10:34 AM, R1 is observed in his room sitting on his bed on top of his catheter tubing, his catheter tubing and bag is sitting directly on the floor in front of his bed, and R1's catheter bag is without a…

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

Based on interview and record review the facility has failed to follow their fire watch policy by not reporting to IDPH (Illinois Department of Public Health) that the sprinkler system is not working in all four units of the facility. This has the potential to affect all 117 residents residing at the facility. Findings Include: Facility's census dated 4/3/25 denotes 117 residents. Facility Fire Watch Policy denotes to establish a process for fire safety in the event that the fire protection system fails or is not operating (includes service being performed on system). When the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Facility incident report dated 1/23/25 denotes on 1/22/25 description of occurrence: Facility is on Fire Watch related to broken pipe. Fire Dept (Department) has been made aware. Occurrence…

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 follow their practice and ensure to transcribe a physician order to include the right dose, right diagnosis, and duration for prednisone 60mg (milligram) tablets, and failed to complete an order for Norco 7.5mg-325mg for 3 days for one of one resident (R1) reviewed for physician orders. Findings include: R1's face sheet shows R1 has diagnosis of osteoarthritis, aftercare following joint replacement, COPD, weakness, lack of coordination, low back pain, and hypertension. On 11/13/24 at 1:46pm V2 (Director of Nursing) said the physician order Prednisone 60 mg by mouth for 5 days for R1 on 6/14/24 was for COPD exacerbation. V2 said the Nurse should have clarified the order with the physician, and transcribed the order as given. V2 said if the nurse was not sure of the order, she should have contacted her (V2) or the physician for clarification. V2 said the Nurse needs reeducation on transcribing verbal orders. V2 said the order for prednisone 1mg (60mg) is not correct as transcribed by the nurse on the medication administration…

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 ADL (activity of daily living) care to a dependent resident and provide incontinence care at least every two hours, and failed to ensure residents are provided a bath per facility policy. This affected four of four residents (R1, R3, R4, and R6) reviewed for activity of daily living. Findings include: 1. On 10/1/24 at 11:50am R6 was observed alert and orientated to person, place, time, and situation. R6 said she had not been changed for hours. R6 said she was changed at 11:00am, and prior to that she was changed at 5:30am. R6, with assist from V1 (CNA/Certified Nurses Aide) showed surveyor her gown, shirt, and mattress, R6's shirt, gown and mattress was observed soiled in urine and smelled of urine. 10/3/24 at 2:26pm V9 (ADON-Assistant Director of Nursing) said staff should be checking and changing residents every two hours, they should apply skin barrier cream as appropriate to prevent moisture from breaking down the skin. R6's care plan dated 4/13/24 denotes resident has ADL care performance deficit…

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 supervision during smoking breaks for a resident (R8) identified to require supervision. This affected one of three residents (R8) reviewed for safety during smoking. Findings include: On 10/1/24 11: 20am R8, R9, R10 were observed smoking outside on the patio. Staff was observed inside the facility. V13 (Activity aide) said she was monitoring the resident but had to step away. R8 was observed with holes in his shirt and pants. There was no ash tray observed for R8, R9, R10 to use while smoking. Greater than 200 cigarettes butts were observed on the ground. There was a brown flowerpot observed melted (place on the ground), half of the flowerpot was missing. There was a circular burn area noted on the metal table with melted debris on the table and ground. V13 said the residents were putting their cigarettes out in that flowerpot. V13 said she did not report that to anyone. V13 said there was an ash tray just out here, V13 was asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident call light is within reach. This deficiency affects one (R44) of three residents in the sample for 26 reviewed for Accommodation of needs and Resident safety. Finding include: On 8/13/24 at 12:15PM, Observed R44 lying in bed. His call light is placed on top of his bedside tray table away from him and unable to reach. He is alert and oriented, able to verbalize needs to staff. R44 said the CNA (Certified Nurse Assistant) transferred him back to bed after his therapy this morning. He said that if he cannot reach his call light he will yell for help until someone comes to his room. Called V24 RN (Registered Nurse) and showed observation made. V24 said that his call light should be within his reach. She moved the bedside tray table next to his bed and placed the call light within reach. On 8/13/24 at 1:01PM, Informed V2 DON (Director of Nursing) of above observation and asked for policy. R44 is admitted on [DATE] with…

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 post information including names, address (mailing and email) and telephone numbers of the State Long Term Care (LTC) Ombudsman Program in a form and manner thats accessible and understandable to residents and resident's representatives. This deficiency affects one (R116) of three residents in the sample of 26 reviewed for Resident rights. Findings include: On 8/13/24 at 11:06 AM, V16 (Family member) presented concerns and frustrations regarding care of R116 received from the facility. V16 also said that he is not aware of the State Agency and advocacy group that he can reach out to for his concerns. At 11:30AM, Rounds made with V16 (Social Service Director-SSD) and V16 (Family member) to the front lobby bulletin board. Observed no posting for State of Long-Term Care (LTC) Ombudsman Program contact information. V6 (SSD) said that there should be posting about State of LTC Ombudsman Program to the front and in all units that is visible and accessible to the resident and family member. Rounds made to Medicare…

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 a resident (R111) from verbal abuse by a staff member. This deficiency affects 1 (R111) of 4 residents in a sample of 26 reviewed for abuse prevention. Findings include: On 8/15/2024 at 12:05 PM an interview with V1 (Administrator) was conducted. V1 stated the alleged event on 6/6/2024 between R111 and V27 (Housekeeper) was investigated and found substantiated. V1 said V27 has been terminated and no longer works at the facility. R111 discharged to community on 8/9/2024 as planned. On 8/15/2024 at 12:54 PM interview with V6 (Social Service Director) completed. V6 stated she was a witness to the verbal abuse of R111 by V27. Review of Facility Incident Report completed by V1 on 6/12/2024 indicated on 6/6/2024 at 12:00PM, R111 was in his room when V27 entered to clean and started moving his items without consent. R111 asked V27 not to touch his items, however V27 did not heed to the request and continued to clean along with moving the items R111 stated V27 became upset with the request and started using profanity. R111…

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 a comprehensive person-centered care plan that meets resident's choice of activities and Activities of Daily Living (ADL). This deficiency affects one (R116) of three residents in the sample of 26 reviewed for developing comprehensive care plans. Findings include: On 8/13/24 at 11:15AM, V16 (Family member) presented the concerns regarding his fathers care, R116. V16 said his father was admitted last month in July. He said that his father had stroke and was admitted to this facility for rehabilitation. R116 was only given a shower once since admission. He added that R116 does not go to activities after his therapy, he just lays in bed. The facility does not motivate his father to participate. On 8/13/24 at 11:26AM, R116 was observed sitting in his wheelchair. His hair is disheveled, oily, and unkempt. He is not shaved. He has a scraggly beard (when growth gets out of hand and starts to look unkempt). He said that he only took 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 ensure that residents receive necessary services to maintain good grooming and personal hygiene. This deficiency affects two (R44 and R116) of three residents in the sample of 26 reviewed for ADL (Activity of Daily Living) care services. Findings include: 1. On 8/13/24 at 11:15AM, V16 (Family member) presented the concerns regarding his fathers care, R116. V16 said his father was admitted last month in July. He said that his father had a stroke and was admitted to this facility for rehabilitation. R116 was only given a shower once since admission. On 8/13/24 at 11:26AM, Observed R116 sitting in his wheelchair. His hair is disheveled, oily, and unkempt. He is not shaved. He has a scraggly beard (when growth gets out of hand and starts to look unkempt). He said that he only took shower once since he was admitted last month. R116 is admitted on [DATE] with diagnosis listed in part but not limited to Cerebral infarction due to occlusion 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 implement its policy on prevention of pressure ulcer's by failing to ensure low air loss mattress is properly functioning and failing to apply bilateral heel protector's when in bed as ordered by physician. This deficiency affects two (R44 and R91) of three residents in the sample of 26 reviewed for Pressure ulcer prevention program. Findings include: 1. On 8/13/24 at 11:40AM, observed R91 lying in bed in semi sitting position, leaning to his right with his head hanging from the bed. Noted his LAL (Low air loss) mattress sagging and deflated, R91 sinks in the mattress. R91 has bilateral heel protectors. Called V22 (CNA-Certified Nurse Assistant) and showed observation. V22 said that the LAL mattress should not be deflated like this, it's not working properly. She disconnected and reconnected tubing from the LAL mattress and started to inflate. She said that they should check the LAL mattress if its function properly. She is the assigned…

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 foot care and preventive treatment to a diabetic resident to prevent podiatric complications. This deficiency affects one (R44) of three residents in the sample of 26 reviewed for Diabetic Foot care services. Findings include: On 12:15pm observed R44 lying in bed. R44 was observed with long dirty fingernails. R44 is alert and oriented, able to verbalize needs to staff. Called V24 (Registered Nurse-RN) and showed long dirty fingernails of R44. V24 said that R44 is diabetic. Surveyor requested to see R44's toenails. V24 removed his bilateral socks and observed long toenails. V24 said that podiatrist should trim his toenails. On 8/14/24 at 12:30PM, Informed V1 (Administrator) and V2 (Director of Nursing-DON) of above concerns identified. V2 said that for diabetic residents the podiatrist will trim the toenails. On 8/15/24 at 10:30AM, V2 said that residents who need to be seen by Podiatrist will be scheduled within a month 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.

Based on observation, interview and record review the facility failed to ensure pain was assessed before and during wound care, for 1 of 3 residents (R65) in a sample of 26 reviewed for pain management. Findings include: On 8/13/2024 at 11:20am R65 was observed in bed with a dressing to her left foot. R65 said I have a dressing change every other day to my foot and the wound care nurse does not give me any pain medication. I know I have a stronger one than Tylenol. I have hydrocodone and she just says its not in as of yet. It's been over a month. R65 said her pain level is a 6. On 8/13/2024 at 12:47pm V23 (Wound-Care Nurse) said R65 is alert and oriented times two to three with forgetfulness, she does not say she's in pain when I start her wound care. When I ask R65 if she's in pain she says no. On 8/13/2024 at 12:55pm V2 (Director of Nursing-DON) said I expect the wound care nurses to ask resident's if they have any pain before starting a wound care dressing and while completing the wound care dressing. An admission record indicates that R65 has a diagnosis of peripheral vascular…

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 daily refrigerator temperature check inside the resident room to ensure proper temperature and food safety. This deficiency affects two (R29 and R128) of 2 residents in the sample of 26 reviewed for Resident safe food storage. Findings include: On 8/13/24 at 11:33AM, observed R29's refrigerator monitoring temperature log was not done this morning. The only entry on the log is 8/1/24. Observed 3 puddings, 1 foam cup of orange juice, 1 plastic fruit container not labeled or dated. Called V19 (Registered Nurse-RN) and showed observation made. V19 said that maintenance is the one monitoring and recording the resident's refrigerator temperature daily. V19 said that food should be labeled to know when to discard it. V19 said she did not know why the temperature log was not completed. On 8/13/24 at 11:35AM, Observed R128's refrigerator monitoring temperature log was not done this morning. The only entry log is 8/1/24. Observed 5 yogurts, 5 fresh fruit cups, 1 container of ham, 6 juices, 4 milk cartons 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 observations, interviews, and record reviews the facility failed to follow their housekeeping policy and procedures by not ensuring the memory care unit was clean and free of odors. This failure applied to all 21 residents currently located in the memory care unit. Findings include: On 06/14/2024 at 2:42 PM Observed the memory care unit with strong odors including urine just before entering the unit and directly near the entrance of the unit. On 06/14/2024 at 2:47 PM Observed a strong urine odor near R5's room located on the memory care unit. On 06/14/2024 at 2:56 PM Observed strong odors including urine near R7's room located on the memory care unit. The facility's census report documents a total of 21 residents located on the memory care unit. On 06/17/2024 at 11:45 AM V2 (Assistant Director of Nursing) stated she had observed strong odors just as you enter the memory care unit. V2 stated she did wonder what the source of the smell was. V2 stated she believes V9 (Environmental Manager) was notified of the smell but could not confirm. V2 stated it would be expected that V9…

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 interviews and record reviews the facility failed to follow their policy and procedures for notice of change in condition by not ensuring resident's family members were notified of changes in resident health status and medications. This failure applied to three of four residents (R4, R5, and R7) reviewed for notice of change. Findings include: 1. R4 is a [AGE] year-old female who was admitted to the facility 03/09/2023 with a diagnoses history of Lower Back Pain, Spinal Stenosis, Generalized Muscle Weakness, and Difficulty in Walking. On 06/14/2024 at 4:25 PM R4 is observed in her room sitting in the wheelchair. R4 stated she did select V21 (R4's Family Member) as her emergency contact and had informed the facility that she did want her sister notified about any changes in her health. R4's face sheet documents V21 is her emergency contact. R4's Thyroid Labs collected 04/12/2024 and 04/24/2024 documents abnormal Thyroid Hormone levels. R4's current physician orders document an order effective 04/23/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure that a resident received physical therapy services for which the resident was assessed and care planned for, with physician orders in place. This failure applied to one of one resident (R4) reviewed for physical therapy services. Findings include: R4 is a [AGE] year-old female who was admitted to the facility [DATE] with a diagnoses history of Lower Back Pain, Spinal Stenosis, Generalized Muscle Weakness, and Difficulty in Walking. On [DATE] at 4:25 PM R4 is observed in her room sitting in the wheelchair. R4 stated she has been in the facility since March of 2023, was discharged from PT (Physical Therapy) October of 2023 and wanted to know when she could resume but even after repeated requests there was no follow up from the PT department. R4 stated her family requested to have a meeting regarding her Physical Therapy and only wanted to speak with the Physical Therapy Director. R4 stated the facility included the Director of Nursing 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 observation, interview, and record review, the facility failed to follow their policy on resident's rights by failing to knock on the door before entering a resident's room for 4 of 8 residents (R107, R125, R236, R237) in a sample of 28. Findings include: On 10/17/2023 at 12:15 PM, V18 (CNA - Certified Nurses Assistant) was observed entering R107's room with a lunch tray and without knocking. On 10/17/2023 at 12:17 PM, V18 was observed entering R125's room with a lunch tray without knocking. On 10/17/2023 at 12:20 PM, V18 was observed entering R236 room with a lunch tray and not knocking. On 10/17/2023 at 12:30 PM, V18 was asked what she should do before entering a resident's room. V18 stated, I should sanitize my hands. On 10/17/2023 at 1:30 PM, V2 (Director of Nursing-DON) stated, I expect all staff to knock before entering and wait for permission to enter. Facility Policy: Resident Rights Protocol for All Nursing Procedures. Purpose: To provide general guidelines for resident rights while caring for the resident. Preparation: 1. Prior to having direct-care…

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 a dependent resident. This deficiency affects one (R185) of three residents in the sample of 28 reviewed for providing Activity of Daily Living (ADL) Care. Findings include: R185 was admitted on [DATE], with diagnoses listed as Metabolic encephalopathy, Multiple Myeloma, Multiple unstageable pressure ulcers, and Adult Failure to thrive. R185's Care plan indicates ADLs functional deficit. She has multiple diagnosis and past medical history impeded her to continue to perform ADLs. MDS ( Minimum Date Set Assessment) admission assessmen,t dated 10/6/23 Section GG Functional Abilities and goals, indicate dependent in ADLs. On 10/17/23 at 12:05PM, R185 was lying on the bed with family members at bedside. R185's fingernails were long and dirty. On 10/18/23 at 10:34AM, R185 was lying on the bed with family members at bedside. R185's fingernails were still long and dirty with black matter underneath nails Showed observation 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 follow manufacturer recommendation in using low air loss mattress to a resident who has multiple unstageable pressure ulcers. This deficiency affects one (R185) of three residents in the sample of 28 reviewed for pressure ulcer prevention management. Findings include: R185 was admitted on [DATE], with diagnoses including Pressure ulcer of sacral region unstageable, Pressure ulcer of left hip stage 4, Pressure ulcer of left buttock unstageable, Pressure ulcer of right ankle unstageable, Pressure ulcer of right heel unstageable, Pressure ulcer of left heel unstageable, and Pressure ulcer of right shin unstageable. admission skin assessment/Braden scale, dated 10/1/23, indicated she is at high risk for developing skin impairment. Physician order sheet (POS) indicates: Pressure reducing Low Air loss Mattress. R185's Care plan indicates: R185 was admitted with multiple pressure ulcers. She is at risk for further breakdown due to decreased…

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 interventions to monitor resident for one of one resident (R51) in the sample of 28 reviewed for safety. Findings include: On 10/17/2023 at 9:15 AM, no posting was observed anywhere at the front desk or lobby indicating what items can and/or cannot be brought inside the facility. On 10/17/2023 at 12:22 PM, V25 (Certified Nursing Assistant/CNA) said she has observed empty bottles of alcohol/liquor in R51's room before. V25 said she removes it from the room, and takes it to the Director of Nursing (DON). V25 said she had asked R51 who has been bringing him the alcohol/liquor, but R51 would not tell her. On 10/19/2023 at 9:37AM, V10 (Social Service Director) said R51 uses online food and grocery delivery service to order the liquor, or R51's friends will bring it to him. V10 also said each time an incident like this occurs, the care plan should be updated and implemented. On 10/19/2023 at 11:03AM, V37 (Psychiatry Physician Assistant) stated R51 said he obtained the liquor through online food 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 obtain physician order for medical indication and size for using indwelling catheter to a resident. This deficiency affects one (R185) of three residents in the sample of 28 reviewed for Urinary Catheter Management. Findings include: On 10/17/23 at 12:05 PM, R185 was lying on the bed with family members at bedside. R185 had indwelling catheter connected to drainage bag, draining to dark yellow orange urine. Family member said R185 was admitted on [DATE] from the hospital. R185's medical records indicated she was admitted on [DATE],3 with diagnoses including Metabolic encephalopathy, Multiple Myeloma, and Multiple unstageable pressure ulcers. Physician order sheet indicates: (indwelling) Catheter. No medical indication, no catheter size and balloon size documented. On 10/18/23 at 9:48 AM, V2, Director of Nursing, said if resident is admitted with an indwelling catheter, they have to get an order for medical indication, catheter and balloon…

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

Based on observation, interview, and record review, the facility failed to label ongoing tube feeding for one of two residents (R36) reviewed for tube feeding in a sample of 28. Findings include: R36's Physician Order Report, dated 09/19/2023 - 10/19/2023, indicated admit date of 12/21/2019, diagnoses including gastrostomy status and dysphagia following cerebral infarction, and order for enteral feeding with order date of 01/16/2023. On 10/17/2023 at 10:48 AM, R36's tube feeding was observed attached to R36, unlabeled. On 10/17/2023 at 10:48 AM, V21 (Agency nurse) stated the tube feeding should be labeled before attaching to the resident. On 10/18/2023 at 9:50 AM, V2 (Director of Nursing) stated all tube feeding should be labeled because if it is not, the tube feeding could pass the acceptable length of time of treatment and get spoiled. Facility Policy: Title: Gastric Tube Feeding via Continuous Pump Revised August 2008 Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Steps in the Procedure: 2. Properly…

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 residents' refrigerator for three of three residents (R41, R51, R44) observed for food safety in a sample of 28. Findings include: 1. On 10/17/2023 at 10:45 AM, R44's refrigerator was observed with undated food items inside with no thermometer and temperature log. On 10/17/2023 at 10:48 AM, V22 (Registered Nurse/RN) said the refrigerator's temperature should be monitored on a daily basis by the night shift. V22 also said there should be thermometer inside the refrigerator, and food items should be dated. 2. On 10/17/2023 at 10:46 AM, R51's refrigerator was observed with undated food items inside with no thermometer and temperature log. 3. On 10/17/2023 at 10:47 AM, R41's refrigerator was observed with undated food items inside with refrigerator-cooler temperature log not indicating the month and year, and missing entries from 1st to 25th. On 10/17/2023 at 10:48 AM, V21 (Agency Nurse) said the refrigerator's temperature should be monitored in a daily basis. On 10/18/2023 at 9:50 AM, V2 (Director 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.