Allure Of Sterling

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to report an allegation of sexual abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 5.The findings include:1) A statement dated 11/19/25 by V9 Certified Nursing Assistant - CNA showed she went to R1's room around 8:30 PM to assist her to bed. V9 knocked on the door, stated who she was and walked in. V9 observed R1 on her bed. R1's right foot was on the floor; her left leg was half on the bed and half on the floor. R2 had his right hand on the wall, and his left hand was under R1's right shoulder. R2 was standing with his back to V9; she saw his butt. R2 was not laying on top of R1.A written statement (no date) by V8 Licensed Practical Nurse showed, R1 stated to her that she did not know who wanted the information .and stated they had sex.The facility did not have any paperwork to show Illinois Department of Public Health was contacted with an initial allegation of abuse or a final investigation.On 11/27/25 at 9:09 AM, V1 Administrator…

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 investigate an allegation of abuse in June 2025 for 1 of 3 residents (R1) reviewed for abuse in the sample of 5.The findings include:The Social Service Note dated 6/9/25 at 4:08 PM for R1 showed, this writer was informed by CNA that resident was interested romantically in another resident in the memory care unit. This writer spoke with both R1 and the other resident (R3) and educated them to utilize public spaces to spend time together. This writer asked them not to spend any time together in each other's rooms. R1 and peer both agreed and stated they want to take it slow. Medical Director in facility and notified. No new orders. Voicemail left for V10 to notify. Requested call back.On 12/1/25 at 9:14 AM, V10 (R1's daughter/power of attorney - POA) stated there was an incident in June 2025 with R1 and R3 but there wasn't any documentation about what happened. V10 stated she found out recently from a CNA that R1 was in R3's bed and R3 had his pants down.…

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 resident medical records contained complete and accurate information for 1 of 3 residents (R1) reviewed for medical records in the sample of 5.The findings include: The Social Service Note dated 6/9/25 at 4:08 PM for R1 showed, this writer was informed by CNA that resident was interested romantically in another resident in the memory care unit. This writer spoke with both R1 and the other resident (R3) and educated them to utilize public spaces to spend time together. This writer asked them not to spend any time together in each other's rooms. R1 and peer both agreed and stated they want to take it slow. Medical Director in facility and notified. No new orders. Voicemail left for V10 to notify. Requested call back.On 12/1/25 at 9:14 AM, V10 (R1's daughter/power of attorney - POA) stated there was an incident in June 2025 with R1 and R3 but there wasn't any documentation about what happened. V10 stated she found out recently from a CNA that R1 was in R3's bed and R3 had his pants down. V10 stated they were split up…

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 at risk for elopement was supervised for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of 3.The findings include:R3's admission record documents he was admitted on [DATE] with a diabetic foot ulcer and cellulitis. R3's elopement evaluation of 8/5/25 shows he had a history of elopement or attempted elopement while at home. Scoring a 1 for risk of elopement. No risk factors for elopement were identified, and no clinical suggestions or interventions were checked on the form.On 8/9/25 at 8:50 AM, V6 Licensed Practical Nurse (LPN) said on 8/5/25 R3 was observed going to the front door asking for family members to give him a ride. V6 said V8 Registered Nurse placed a wander guard bracelet on him so if he was attempting to go outside the alarm would sound. V6 did not recall where the wander guard came from or who gave it to V8 to put it on him. V6 said the next day on 8/6/25, R3 went to the front door 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 prevent resident to resident physical abuse for one resident (R3) of three residents reviewed for abuse in the sample of 3. The Findings include: Comprehensive Cognitive Assessment indicates R3 is moderately impaired and has diagnosis of Mild Intellectual Disabilities. Incident Investigation Report dated 6/6/25 at 2:45pm indicates R3 was asked if someone hit her and R3 responded, Yes. My Roommate. Incident Investigation Report dated 6/6/25 at 2:45pm indicates R2 denied hitting R3 and stated that if she did, she didn't mean to. On 6/6/25 at 2pm, R3 was lying in bed and when asked if her previous roommate (R2) had ever hit her. R3 responded Yes. When asked where she was hit, R3 made eye contact and stated, All over. R3 denied being physically hurt. According to resident Census/Room assignments, both R2 and R3 were roommates until 5/28/25 when R2 was moved to another room on the same hall. R3 did not have another roommate after 5/28/25. Current Comprehensive Assessment indicates R2 is independent with mobility.…

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 allegations of abuse to the Abuse Coordinator for three residents (R1, R2, R3) of three residents reviewed for abuse in the sample of 3. Findings include: Comprehensive Cognitive Assessment indicates R1 is moderately impaired and has diagnosis of Mild Intellectual Disabilities. On 6/5/25 at 1:15pm R1 stated (with V1, Administrator present) that [female staff member name] threw her up against the wall and she hit the left side of her head. R1 stated it hurt, but she didn't cry and there was no bump or anything. R1 identified [female staff member name] as a night shift CNA (Certified Nurse Assistant). R1 was unable to state the day/date of this incident. On 6/6/25 at 11:30am R1 stated (with V5, Hospice RN/Registered Nurse present) that [female staff member name] got her dressed for bed one night and then threw her against the wall getting her into bed. R1 stated that she hit the left side of her head It didn't hurt, I didn't cry but it made me mad. R1 stated that [female staff member name] does not have the temperament…

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 one resident (R1) from further potential abuse for 1 of three residents reviewed for abuse in the sample of 3. Findings include: On 6/5/25 at 1:15pm R1 stated (with V1, Administrator present) that [female staff member name] threw her up against the wall and she hit the left side of her head. R1 stated it hurt, but she didn't cry and there was no bump or anything. R1 identified [female staff member name] as a night shift CNA (Certified Nurse Assistant). On 6/6/25 at 11:30am R1 stated (with V5, Hospice RN/Registered Nurse present) that [female staff member name] got her dressed for bed one night and then threw her against the wall getting her into bed. R1 stated that she hit the left side of her head, It didn't hurt, I didn't cry but it made me mad. R1 stated that [female staff member name] does not have the temperament for the job and has a bad attitude. R1 stated that she told V7, LPN (Licensed Practical Nurse) the nurse who comes in the morning and stated V7 told R1 she would report her concerns. R1 never referred…

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 representative after a fall with injury, and failed to notify the representative that the resident was sent out to a local hospital for 1 of 3 residents (R1) reviewed for resident injury in the sample of 8. The findings include: R1's admission Record, provided by the facility on 5/14/2025, showed he was admitted to the facility on [DATE] with diagnoses including unspecified dementia, malignant neoplasm of head, face and neck, and hypertension. R1's 5/8/2025 Clinical admission assessment showed R1 was confused and had severe cognitive impairment affecting all areas of judgement. The assessment showed R1 had wandering behaviors, was occasionally incontinent of urine and frequently incontinent of bowel. On 5/13/2025 at 9:06 AM, V1 (Administrator) said R1 had 2 falls in the facility on 5/8/2025. V1 said the first fall was earlier, while R1's family was in the building. V1 said R1 had another fall later that night after being put in bed.…

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 monitor food temperatures and failed to monitor and record dishwasher temperatures. This applies to all 90 residents residing in the facility. The findings include: The facility's 9/24/24 CMS (Centers for Medicare and Medicaid Services) 671 form shows 90 residents reside in the facility. 1. On 9/24/24 at 8:53 AM V14 (Dietary Manager) said the dishwasher is a hot water sanitizer, and the temperature gets up to 200 degrees, there is a booster in place. The temperatures are checked before cleaning the dishes from each meal and should be logged and recorded. V14 said it is important to make sure the dishes are sanitized to ensure there is no bacteria that could cause food borne illnesses. The September 2024 dishwasher logs show no monitoring of the temperatures from 9/6/24 until 9/11/24, and no temperature recordings on 9/17/24. The facility's 2024 policy for dishwasher temperatures documents it is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher…

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 the review the facility failed to transfer a resident in a safe manner for 1 resident (R343) and failed to ensure hazardous liquids and disposable razors were inaccessible for 1 sampled resident (R56) and 10 residents outside the sample (R43, R60, R34, R28, R22, R86, R75, R85, R33, R41). The findings include: 1. On 9/26/24 the facility supplied a list of residents able to ambulate or propel independently on the dementia unit. The list included (R43, R56, R60, R34, R28, R22, R86, R75, R85, R33, R41). On 9/24/24 at 12:02 PM, the dementia unit shower room door was unlocked. The handle had a numbered keypad. This surveyor was able to fully access the room alone. Bins of mouth wash, skin and hair cleanser, hand sanitizer, body lotion, baby powder, and shaving cream were in the room. A spray bottle of glass and surface cleanser was hanging from a wire rack in the room. A bin with multiple disposable razors were in the room. On 9/25/24 at 9:16 AM, the shower room door was still unlocked, and the same items were in the room. The body lotion, skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide privacy for a resident during physician appointments for 1 of 1 residents (R13) reviewed for privacy in the sample of 19. The findings include: R13's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including spinal stenosis, difficulty walking and lack of coordination. The 8/26/24 annual resident assessment shows she is cognitively intact. On 9/25/24 at 11:00 AM, R13 said V5 (transportation coordinator) takes me to my doctor appointments but goes back into the office to see the doctor with her. R13 said she has asked (V5) to stay in the lobby as she can go see the doctor by herself, and V5 told her that was not possible, and was responsible for her and not able to let her out of her sight. R13 said she has requested privacy for her appointments, and V5 will not listen. On 9/25/24 at 2:00 PM, V5 said she transports residents to their appointments. She takes the paperwork with her and gives it to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident receiving oxygen had a physician order, failed to ensure oxygen and breathing treatment equipment was changed weekly and stored in a manner to prevent cross contamination for 3 of 3 residents (R19, R82, R14) reviewed for respiratory in the sample of 19. The findings include: 1. R19's face sheet showed a [AGE] year-old female with diagnosis of acute respiratory failure, chronic obstructive pulmonary disease, obstructive sleep apnea, hypertension, and anxiety disorder. On 9/24/24 at 11:04 AM, R19 was in bed. R19 had oxygen being administered via nasal cannula at 2 liters per minute. At 1:30 PM, V7 Licensed Practical Nurse (LPN) said R19 has been on oxygen for at least six months. On 9/26/24 at 8:00 AM, V2 Director of Nursing (DON) said R19 should have an order for oxygen. It used to be as needed. Oxygen is a treatment which requires a physician order. Oxygen tubing and breathing treatment tubing should be dated when…

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 two doses of an ordered antibiotic to 1 of 3 residents (R32) reviewed for hospitalization in the sample of 19. The findings include: R32's face sheet showed a [AGE] year-old male with diagnosis of urinary tract infection, multiple sclerosis, neuromuscular dysfunction of the bladder, calculus of the kidney and ureter, and chronic obstructive pulmonary disease. R32's 5/20/24 local hospital history and physical showed he had a suprapubic catheter and fever of 102 while at the facility. At the hospital R32 was found to have a urinary tract infection (UTI). R32's local hospital 6/2/24 hospitalist note showed R32 was diagnosed with sepsis likely source UTI, osteomyelitis, and infected decubitus ulcers. R32's facility census showed he returned to the facility on 6/4/24 after 14 days in the hospital. R32's 6/15/24 local hospital history and physical showed his workup in the emergency room revealed a urinary tract infection with fever, elevated white…

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 PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 2 residents (R71, R84) in the sample and 1 resident (R72) outside the sample. The findings include: 1. R71's September 2024 order summary report showed an order for modified droplet/precautions with face/eye protection. Verify signage is on outside of door to identify the isolation every shift. R72's September 2024 order summary report showed an order for modified droplet precautions with face/eye protection. Verify signage is on outside of room to identify the isolation every shift. On 9/24/24 at 8:53 AM, V1 (Administrator/Infection Control Preventionist) stated R72 is in a COVID positive room. V1 said her roommate (R71) is also a COVID positive resident. On 9/24/24 at 10:24 AM, R71 and R72 had signage on the door indicating the room was on special droplet/contact isolation precautions. The sign showed everyone must, including visitors, doctors, and staff, wear an N-95 mask, eye protection, gown and gloves. 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 interview and record review the facility failed to document resident assessments for 2 of 3 residents (R4, R7) reviewed for change of condition in the sample of 13. The findings include: 1. R4's face sheet documents she was admitted to the facility on [DATE] and discharged on [DATE]. R4 had multiple diagnoses including chronic respiratory failure, oxygen dependency, and COPD (chronic obstructive pulmonary disease). The order summary sheet shows an order for oxygen at 2L (liters) continuous. R4 had an order for a full code status. On [DATE] at 8:50 AM, V1 (Administrator) documented during the AM medication pass, nurse entered (R4's) room to observe resident with no pulse and no respirations. Code blue called. This writer assessed resident and CPR (Cardiopulmonary Resuscitation) initiated at 7:50 AM. 911 called and CPR continued until EMS arrived. Resident left facility, with no pulse/respirations at 8:34 AM with [NAME] Machine (chest compression machine) operating. The progress notes did not contain any…

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 medication storage temperatures were monitored, failed to ensure medications were labeled with the open date and expiration date, and failed to ensure expired medications were removed from stock. This failure had the potential to affect all 70 facility residents. The findings include: The facility's 10/17/23 Resident Census and Condition of Residents form showed there were 70 residents in the facility. On 10/17/23 at 02:11 PM the facility's medication storage and labeling task was started. The 400-hall med cart review was witnessed by V4 Licensed Practical Nurse (LPN). There was a fast-acting insulin vial with R322's name which did not have an open or expiration date. An unlabeled fast acting insulin pen had an illegible date on the outside. There was no resident name and no indication if the date was an opened date or expired date. V4 was unable to clarify what was written. There was an insulin pen with R6's name on it with no open dates or expiration dates on the container. On 10/17/23 at 2:25 PM, V4…

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 dignity was provided for a resident during incontinence care for 1 of 2 residents (R33) reviewed for dignity in the sample of 19. The findings include: On 10/17/23 at 9:42 AM, R33 was sitting in wheelchair. V13 CNA (Certified Nursing Assistant) and V14 CNA used a mechanical lift and transferred R33 to his bed to provide incontinence care. V13 and V14 did not pull the curtain closed between R33 and his roommate (R30) who was sitting in a recliner in the room. V13 and V14 undressed R33, changed his wet incontinence brief, cleaned his groin and buttocks and redressed R33. V13 and V14 stated they should have pulled the curtain closed in the room for the resident's privacy and dignity when providing care. On 10/17/23 at 10:10 AM, V2 DON (Director of Nursing) stated curtains are to be pulled before giving any private cares for dignity issues. The Face Sheet dated 10/18/23 for R33 showed medical diagnoses including osteoarthritis, essential…

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 incontinence care for a resident requiring staff assistance for 1 of 1 resident (R27) reviewed for activities of daily living in the sample of 19. The findings include: R27's face sheet showed a [AGE] year-old female with diagnosis of dementia, hypertension, fibromyalgia, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, osteoporosis, rheumatoid arthritis, and muscle weakness. On 10/17/23, R27 was in a high back reclining chair in her room at 09:21 AM, 10:19 AM, 10:58 AM, 11:16 AM, 11:31 AM, and 11:51 AM. On 10/17/23, R27 was in a high back reclining chair in the dining room at 11:51 AM, 12:00 PM, 12:23 PM, and 12:31 PM. On 10/17/23 at 02:00 PM, V6 Certified Nursing Assistant (CNA) and V8 (CNA) transferred R27 from the chair to bed using a total mechanical lift. V8 removed the transfer sling and placed it into a plastic bag to send to laundry. R27's pants were removed and placed in 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 notify emergency services for nearly 30 minutes after a significant change in condition was identified. This applies to 1 of 3 residents reviewed for hospitalizations in the sample of 19. The findings include: R35's admission Record (Face Sheet) showed an original admission date of [DATE] with diagnoses to include type 2 diabetes, stroke, and dementia. R35's Practitioner Order for Life-Sustaining Treatment (POLST, Code Status) form showed R35 selected Attempt Resuscitation/CPR (Full Code) and she also selected Full Treatment. The POLST form was signed by R35 on [DATE]. On [DATE] at 1:30 PM R35 was near the nurses' station. R35 was able, upon request, to self-propel herself to her room. R35 was able to locate her room and she was aware of health conditions to include diabetes and pressure injures to both heels. R35 had normal skin tone and not tremors were not witnessed during the interview. R35 was unable to recall the reason for a recent…

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 residents were offered a restorative program to help them maintain their functional abilities and ROM (Range of Motion). This applies to 2 of 2 resident (R43 and R322) reviewed for Mobility/Restorative in a sample of 19. The findings include: 1. The Face Sheet printed on 10/18/23 shows R43's diagnoses to include osteoarthritis, heart failure, unsteadiness on feet, weakness, and lack of coordination. The MDS (Minimum Data Set) dated 8/7/23 shows R43 is cognitively intact and has not attempted to walk in his room or the corridor and uses a wheelchair for mobility. On 10/17/23 at 11:38 AM, R43 was lying in bed, alert and oriented. On 10/19/23 at 12:23 PM, R43 was lying in bed, alert and oriented. On 10/17/23 at 11:38 AM, R43 said, when he received physical therapy, he used to walk with help all over the facility, now no one will help him walk and he feels that he has lost strength in his legs. R43 said he would be willing to walk to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to monitor a confused resident while she was in the bathroom and failed to ensure a resident was safely positioned in their wheelchair. This applies to 2 of 3 (R273, R33) reviewed for falls in the sample of The findings include: 1. R273's admission Record (Face Sheet) showed an original admission date of 9/21/23 with diagnoses to include lack of coordination, dementia, muscle weakness, and type two diabetes. R273's 9/26/23 Minimum Data Set (MDS) showed she was totally dependent upon staff for transfers. On 10/17/23 at 1:45 PM V16 (R273's Spouse) stated .Therapy is not going well because of her dementia .She had a fall last night in the bathroom. She didn't remember to pull the cord in the bathroom. I think it (R273's fall) was around 10:00 PM. I think they took her to the bathroom and left her in there . R273's 10/16/23 Progress Note from 6:02 AM showed, [R273] was confused this past evening shift when she pulled out her PICC (Peripherally…

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 an air filter on an oxygen concentrator was clean. The facility failed to ensure a nasal cannula was changed weekly and a humidification container on an oxygen concentrator was dated. This applies to 1 of 1 residents (R18) reviewed for oxygen in the sample of 19. The findings include: On 10/17/23 at 9:34 AM, R18 was lying in bed with oxygen on via a nasal cannula. R18 stated she was short of breath that morning and her oxygen saturation was low. R18 had an oxygen concentrator next to her bed that the nasal cannula was plugged into. The orange sticker on the humidification bubbler showed the oxygen tubing was last changed on 8/26/23 at 10:00 PM. The bubbler was half full and did not show when it was last applied/changed. There was a thick layer of dust covering the oxygen concentrator. The filter on the back of the concentrator was supposed to be black but had a thick layer of grayish white material that appeared to be dust. On 10/17/23 at 10:10 AM, V2 DON (Director of Nursing) stated she would pull 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 prevent cross contamination of resident contact surfaces by not removing gloves and washing hands after providing incontinence care for 1 of 1 residents (R33) reviewed for infection control in the sample of 19. The findings include: On 10/17/23 at 9:42 AM, R33 was sitting in wheelchair. V13 CNA (certified nursing assistant) and V14 CNA used a mechanical lift and transferred R33 to his bed to provide incontinence care. V13 and V14 had gloves on; V13 removed R33's pants. V14 put clean, dry sweat pants on R33's lower legs. V13 unfastened R33's wet incontinence brief and took disposable wipes and cleaned R33's groin and penis. V13 discarded the wipes in the trash. V13 did not remove her gloves/change gloves. V13 grabbed the edge of the mechanical lift sling under R33 and pulled it taught. V13 and V14 assisted R33 to turn onto his left side. V13 grabbed the disposable wipes, cleaned his buttocks, and discarded the wipes. V13 and V14 and put 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 interview and record review the facility failed to ensure a physician's plan for care of a resident was ordered and implemented for 1 of 3 residents (R1) reviewed for standard of care in the sample of 7. The findings include: The Face Sheet dated 9/26/23 for R1 showed diagnoses including gastroesophageal reflux disease, vitamin D deficiency, hypertension, heart failure, chronic obstructive pulmonary disease, repeated falls, cataract, hyperlipidemia, urinary tract infection, muscle weakness, macular degeneration, cardiac pacemaker, chronic kidney disease, and hypothyroidism. The Progress Notes dated 8/15/23 for R1 showed R1 was admitted to the facility from the hospital with non-pitting edema to her bilateral lower extremities. The Rehabilitation Nurse Practitioner's Note for R1 dated 8/16/23 showed R1 had a fall outside of a public library, 911 was called and R1 was admitted to the hospital with dehydration and a urinary tract infection. R1 admitted to falling more frequently at home and agreed to go 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.