Elevate Care Waukegan

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report an injury of unknown origin and an allegation of abuse for 2 of 34 residents (R31, R133) reviewed for abuse in the sample of 34. The findings include: 1.On 03/09/2026 at 11:47 AM, R31 was lying in bed with a left frontal hematoma and abrasion to the head. R31 did not respond to verbal stimulation due to his impaired cognition.On 03/09/2026 at 11:55AM, V4 (Certified Nursing Assistant-CNA) stated, I am not sure how (R31) was injured. I am a float CNA. I do not work with (R31) often. On 03/10/2026 at 9:39 AM, V1 (Administrator) stated, I did not know about (R31's) injury until yesterday (03/09/2026) when you asked. I have not talked to the staff yet. On 03/10/2026 at 9:42 AM, V6 (CNA) stated, (R31) had bruising to the head when I started my shift on Thursday (03/05/2026).On 03/10/2026 at 9:55 AM, V8 (Registered Nurse-RN) stated, I saw (R31's) bruise on Sunday (03/08/2026). I did not report the wound; the wound was not new; it was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refer a resident for a Preadmission Screening and Resident Review (PASARR) Level II evaluation after a new diagnosis of psychosis for 1 of 5 residents (R17) reviewed for PASARR in the sample of 34. The findings include:R17's Face Sheet shows he admitted to the facility on [DATE], with diagnoses of generalized anxiety disorder and major depression. R17's Face Sheet shows he received the diagnosis of Psychosis not due to substance or known physiological condition on 1/30/24 during his stay. R17's PASARR Level 1 Screening, dated 10/3/22, shows he does not have any serious mental illness diagnoses and a Level 2 screen is not indicated. On 3/11/2026 at 11:15 AM, V28 (Social Service Coordinator) said corporate does PASARR screening for residents prior to admission. V28 said she is not sure who checks them for accuracy. V28 said if a resident receives a new severe mental illness diagnosis, corporate will refer them for a PASARR level II evaluation. V28 said…

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

Based on observation, interview, and record review, the facility failed to ensure a resident with dysphagia was supervised during meals. This applies to 1 of 34 residents (R141) reviewed for safety in the sample of 34. The findings include: R141's face sheet shows he has diagnoses including dysphagia, hemiplegia and hemiparesis following non traumatic subarachnoid hemorrhage affecting right dominant side, type 2 diabetes, and carpal tunnel syndrome left upper limb. R141's Physician Order Sheets, dated March 2026, shows orders for mechanical soft diet and nectar thick liquids. On 03/09/2026 at 12:17 PM, R141 was eating in his room during the noon meal. R141 was sitting in his wheelchair with his meal tray on his bedside table. He was served beef stew and green beans. R141 was drinking water (not thickened) and coughing after water and bites of food. On 03/10/2026 at 1:00 PM, V27 (Certified Nursing Assistant) said, (R141) is on the list to be supervised and assisted during meals for safety. (R141) is on mechanical altered diet and nectar thickened liquids, he should not be eating in…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter was secured to prevent pain and/or injury for 1 of 5 residents (R1) reviewed for urinary catheters in the sample of 34.The findings include:On 03/09/2026 at 10:19 AM, R1's urinary drainage bag tubing was hanging off the bed. The drainage tubing was being fully supported by the indwelling urinary catheter inside of R1's bladder. R1 did not have an external securing device for the indwelling urinary catheter. On 03/09/2026 at 10:22 AM, V9 (Certified Nursing Assistant) said, (R1's) catheter securing device may have fallen off.On 03/10/2026 2:29 PM, V10 (Licensed Practical Nurse) said, We use catheter securing devices. It prevents yanking on the catheter that may cause the catheter to come out of the urinary urethra causing damage or pain to a resident.The facility's Urinary Catheter Care policy, revised 02/14/2019, shows, indwelling catheters may be secured to prevent trauma and tension.

Based on observation, interview, and record review, the facility failed to provide nutritional supplements for a resident at risk for weight loss. This applies to 1 of 6 residents (R141) reviewed for weight loss in the sample of 34. The findings include: R141's face sheet shows he has diagnoses including dysphagia, hemiplegia and hemiparesis following non traumatic subarachnoid hemorrhage affecting right dominant side, type 2 diabetes, and carpal tunnel syndrome left upper limb. On 03/09/2026 at 12:17 PM, R141 was eating in his room during the noon meal. R141 appeared thin and underweight. R141 was served beef stew and green beans. There was no frozen nutritional supplement provided with his meal. On 03/10/2026 at 1:00 PM, V27 (Certified Nursing Assistant-CNA) said the frozen nutritional treats should come on the resident's meal tray from the kitchen. R141's dietary note, dated 1/10/26, documents he is underweight at 103 lb (pounds) continue supplements frozen nutritional treat and nutritional shake twice a day. R141's current care plan shows he is at risk for compromised…

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 weights for a resident with a gastrostomy tube for 1 of 7 residents (R191) reviewed for gastrostomy tubes in the sample of 34.The findings include: On 03/09/2026 at 10:06 AM, R191 was in bed sleeping. R191's gastrostomy tube was connected to the feeding pump. Osmolite 1.2 was running at a rate of 70 cubic centimeters (cc)/hour.On 03/10/2026 at 1:19 PM, V2 (Director of Nursing) said resident weights are checked on admission, weekly x 4 weeks to get the residents baseline weight, and then monthly. V2 said for residents on gastrostomy tube feedings, the Dietician needs weights to make sure the tube feeding is meeting the caloric needs of residents.R191's Weights and Vital Summary, dated 3/10/26, shows the only weight obtained for R191 was done on 3/10/26.R191's Physician Orders (POS) for March 2026 shows R191 was admitted on [DATE]. This same POS shows orders Weigh upon admission & weekly x 4 and weigh monthly and record. This POS…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen was administered according to physician orders for 1 of 9 residents (R162) reviewed for oxygen in the sample of 34.The findings include:On 03/09/2026 at 9:59 AM, R162 was sleeping in bed wearing a nasal cannula. R162's oxygen concentrator was set at 5 Liters (L).On 03/10/2026 at 9:38 AM, R162 was in bed watching TV with a nasal cannula on. R162's oxygen concentrator was set at 5 Liters.On 03/10/2026 at 1:19 PM, V2 (Director of Nursing) said the nurse should follow the oxygen order in Physician Orders when setting the level of oxygen being administered. Residents can have respiratory issues if oxygen is set too high.R162's Physician Orders dated 6/18/2025 shows, On 3L/min of oxygen via nasal cannula.The facility's Oxygen Therapy Policy, dated 12/1/2024, shows, It is the policy of this facility that oxygen shall be used in a safe and effective manner in accordance with applicable rules and regulations and the standard of care. Set-up and administration of oxygen: Attach the nasal…

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 discontinue an antibiotic as ordered for 1 of 34 residents (R57) reviewed for unnecessary medication in the sample of 34.The findings include:R57's Face Sheet shows that he admitted to the facility on [DATE], with diagnoses of: acquired absence of right great toe, right toes, left great toe and osteomyelitis.R57's Hospital Discharge Medications, dated 2/8/26, shows an order for cephalexin 500 milligrams (mg)-1 capsule 4 times a day for 7 days.R57's February and March Medication Administration Record shows that he received cephalexin 500mg-1 capsule four times a day from 2/8/26 to 3/11/26. R57's Infectious Disease Nurse Practitioner Note, dated 2/23/26, shows, Patient is on cephalexin 500 mg po (by mouth) four times a day, no end date: however, according to hospital records it was supposed to be only for 7 days. Will verify with nursing staff if someone extended. At present, the patient is clinically stable: afebrile, vital signs stable, no signs 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.

Based on observation, interview, and record review, the facility failed to administer medications as ordered for 2 of 3 residents (R4, R71) reviewed for medication administration in the sample of 34. This failure resulted in 6 errors out of 30 opportunities resulting in a 20% medication error rate.The findings include:1.R4's March 2026 Medication Administration Record (MAR), documents, Metoprolol Succinate Extended Release 50 milligrams; give 1 tablet by mouth once a day, hold medication if resident's heart rate (pulse) is less than 60 beats per minute.On 3/9/26 at 10:02 AM, V15 (Registered Nurse-RN) administered 50 milligrams of Metoprolol to R4. V15 did not assess R4's pulse prior to administering the medication. V15 stated the last time she assessed R4's pulse was around 8 am on 3/9/26. On 3/9/26 at 12:40 PM, V2 (Director of Nursing-DON) stated as per the physician's order, R4's pulse should be checked immediately prior to administering her Metoprolol medication. 2. R71's March 2026 Medication Administration Record (MAR) showed the following medication orders for R71:Duloxetine…

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 psychotropic medications were reordered before running out, resulting in missed doses of lithium and lorazepam for a resident. This applies to 1 of 34 residents (R135) reviewed for medications in the sample of 34. The findings include: On 3/10/26 at 9:03 AM, R135 was lying in bed with a calm demeanor and said there have been a few occasions where R135 missed doses of his lorazepam. R135's Medication Administration Record (MAR) for February 2026 shows R135 missed one dose of Lorazepam on 2/5/26, two doses on 2/26/26, and one dose on 2/27/26. R135's MAR for February 2026 also shows R135 missed two doses of lithium on 2/1/26. R135's February 2026 electronic MAR (eMAR) progress notes show the reason for the missed doses all state awaiting delivery. On 3/10/26 at 1:33 PM, V18 (Licensed Practical Nurse- LPN) said if a resident runs low on a medication, V18 calls the pharmacy. If the resident is already out of a medication, V18 would call and receive an order to retrieve the medication from the locked…

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 staff provided prescribed therapeutic diets. This applies to 2 of 34 residents (R141, R164) reviewed for therapeutic diets in the sample of 34.The findings include:1.R141's face sheet shows he has diagnoses including dysphagia, hemiplegia and hemiparesis following non traumatic subarachnoid hemorrhage affecting right dominant side, type 2 diabetes, and carpal tunnel syndrome left upper limb. On 03/09/2026 at 12:17 PM, R141 was eating in his room during the noon meal. R141 was served beef stew and green beans and two cups of thin liquids. R141 took a sip of water and started coughing. R141 continued to drink his water (not thickened) and requested more water. At 12:25 PM, V4 (Certified Nursing Assistant-CNA) poured water into a cup from the water pitcher on the drink cart. V4 did not add thickener to the water and delivered the water to R141 (there was no thickener solution located on the drink cart). On 03/10/2026 at 1:00 PM, V27 (CNA) said the floor aides pass liquids to the residents. The CNAs…

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 enhanced barrier precautions (EBP) were implemented for a resident who has a pressure ulcer to prevent cross contamination. This applies to 1 of 34 residents (R170) reviewed for infection control in the sample of 34. The findings include: On 03/09/2026 at 10:20 AM, R170's room did not have a EBP sign or isolation cart outside of his room. R170 said he has sore on his right heel. A protective foam dressing was in place to his right heel. On 03/10/2026 at 9:12 AM, R170 did not have an EBP sign posted or isolation cart outside of his room. R170's Physician Order Sheets, dated March 2026, shows there was no order for EBP until 3/10/26. R170's Wound Progress note, dated 3/2/26, shows an unstageable right heel pressure ulcer measuring 1.0 cm (centimeters) x 1.0 cm. Date identified 2/19/26, present on admission. On 03/11/2026 at 9:20 AM, V13 (Infection Control Preventionist) said residents with open wounds should be placed on EBP. V13 confirmed R170 should have been on EBP. The facility's EBP policy, revised…

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 screen, educate, and offer the influenza immunization to a resident upon admission to the facility. The facility failed to administer a pneumococcal immunization to a resident once the resident consented to receiving the immunization. These failures apply to 1 of 5 residents (R163) reviewed for immunizations in the sample of 34.The findings include:R163's admission Record showed R163 was admitted to the facility on [DATE].R163's Immunization Record printed 3/10/26 showed R163 was not screened for, educated on, or offered the influenza immunization until 3/10/26. The record showed R163 has never received a pneumococcal immunization in the facility. R163's Authorization and Release for Pneumococcal form, dated 9/22/25, showed R163 consented to receiving a pneumococcal vaccine on that date after being screened for and educated on the immunization. On 3/10/26 at 1:14 PM, V13 Infection Preventionist (IP) stated residents should be screened for, educated on,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to screen, educate, and offer the COVID immunization upon admission to the facility for 2 of 5 residents (R123, R163) reviewed for immunizations in the sample of 34.The findings include:R123's admission Record showed R123 was admitted to the facility on [DATE].R123's Immunization Record, printed on 3/10/26, showed R123 was not screened for, educated on, or offered a COVID immunization until 3/10/26.R163's admission Record showed R163 was admitted to the facility on [DATE].R163's Immunization Record printed 3/10/26 showed R163 was not screened for, educated on, or offered a COVID immunization until 3/10/26.On 3/10/26 at 1:14 PM, V13 Infection Preventionist (IP) stated residents should be screened for, educated on, and offered the COVID immunization upon admission to the facility. V13 stated R123 and R163 were not offered the immunization until 3/10/26.

Based on interview and record review, the facility failed to protect a resident (R1) from physical abuse by a visitor, and failed to protect a resident (R2) from verbal abuse by a visitor. These failures apply to 2 of 3 residents reviewed for abuse in the sample of 4. The findings include:1.R1's electronic face sheet, printed on 7/19/25, showed R1 has diagnoses including but not limited to severe protein-calorie malnutrition, dysphagia, thrombocytopenia, and dementia without behaviors.R1's facility assessment, dated 7/3/25, showed R1 has severe cognitive impairment and does not exhibit behaviors.R1's care plan, dated 7/3/25, showed, (R1) displays socially inappropriate and maladaptive behavior as manifested by: Attempting to manipulate fecal matter; to draw attention to oneself or a manipulation for special privileges. These symptoms are related to anger/agitated depression, communicating anxiety and restlessness, and trying to spit on staff.The facility's document titled, Preliminary 24-hour Incident Investigation Report, dated 7/17/25, showed, On 7/17/25 it was reported to (V1,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report abuse allegations to the State Agency for 1 of 4 residents (R2) reviewed for abuse in the sample of 4. The findings include: R2's admission Record, dated 6/17/25, shows R2 is a [AGE] year-old male admitted to the facility on [DATE], with an admitting diagnosis of Amyotrophic Lateral Sclerosis (ALS). R2's current care plan, initiated on 3/31/25, shows R2 is very welcoming, alert, and oriented to person, place, time, and situation. On 6/17/25 at 9:50 AM, R2 said the Certified Nursing Assistant (CNA), V10, tried to break his oxygen concentrator by hitting it, and when she could not break it, she turned it off. R2 said V10 disabled his call light by pulling it out of the wall. R2 said the incident happened prior to 5/20/25, and he thinks it was during the night shift. R2 said he told a male nurse about it, and the nurse was going around getting statements, and they conducted an investigation. On 6/17/25 at 12:45 PM, V1, Administrator, said she did…

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 residents who are dependent on staff for activities of daily living received oral care for 2 of 6 residents (R1, R2) reviewed for oral care in the sample of 6. The findings include: 1. R1's Physician Orders for April 2025 shows and order dated 7/16/24, Oral care as needed and oral care every 8 hours. R1's Care Plan, dated 8/26/24, shows, (R1( has oral/dental health problems (cavities) related to poor oral hygiene and to provide mouth care as per Activities of Daily Living (ADL) personal hygiene. R1's Nurse Practitioner Progress Note, dated 4/7/25, shows, (R1's) cognitive function continues to improve, answers simple questions appropriately. On 4/8/25 at 10:37 AM, V4, Certified Nursing Assistant (CNA), had just performed incontinence care, and was washing R1's face. V4 gathered dirty linen and garbage and told R1, see you later. R1 was laying in bed on her back, with a clean gown and bedding. R1 had white/yellow debris in between her bottom teeth, and a film over her top and bottom teeth. R1 was able 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 observation and interview, the facility failed to ensure food was palatable for resident consumption. This applies to 4 of 32 (R71, R38, R103, R34) residents in the sample of 32. The findings include: On 1/13/2025 at 1:33PM, the cooked chicken for the lunch service was on the steam table waiting to be served. However, staff had to reheat the chicken in the oven prior to plating. On 1/13/2025 at 1:11PM, R71 stated the chicken was very hard and it was tough. R71 said she couldn't eat it. On 1/13/2025 at 1:10PM, R38 said his chicken was very dry and only ate half of the breast. On 1/13/2025 at 1:08PM, R103 said his chicken was a tiny drumstick and a wing and tasted overdone. On 1/13/2025 at 10:35AM, R34 said, The food; it is terrible here. On 1/13/2025 at 1:23PM, the facility provided a test tray to surveyors, which included chicken, carrots, mashed potatoes, and cornbread. The chicken on the test tray provided appeared dry and overcooked. Upon tasting the chicken on the lunch tray, it tasted dry and the texture was tough. On 1/15/2025 at 9:04AM, V26, Assistant Food Service…

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 assess and approve a resident to self-administer medications, which applies to 1 of 3 residents (R116) reviewed for self-administration of medication in a sample of 32. The findings include: R116's Facesheet, printed on 1/15/25, showed R116 to be a [AGE] year old male admitted to the facility with diagnoses which include: chronic respiratory failure with hypercapnia/hypoxia, tracheotomy, and chronic obstructive pulmonary disease. On 1/14/25 at 12:45 PM, R116 started a nebulizer treatment in his room by himself. R116 stated the respiratory therapist (V6-Respiratory Therapy Manager) brought him the stuff (ampule of medication), and R116 started the treatment himself. On 1/14/25 at 2:00 PM, V2, Director of Nursing, stated for a resident to be able to self-administer medications, they need to be assessed and have a physician order to make sure they can take a medication correctly. This applies to all types of medications (pills, inhalers,…

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

Based on interview and record review, the facility failed to ensure a resident was free from resident to resident physical and verbal abuse. This applies to 1 of 32 residents (R84) reviewed for abuse in the sample of 32. The findings include: A facility provided Final Incident Investigation report, completed on 11/7/24 by V1 (Administrator), shows on 11/1/24, there was a physical altercation between R84 and R166. Both residents are described as being alert and oriented with no cognitive impairments. The report documents R84 had gone to R166's room to discuss something with him and they had a verbal disagreement, which escalated to R84 being knocked out of her chair onto the floor. The report documents V15 (CNA/ Certified Nursing Assistant) had witnessed the incident and intervened removing R84 from R166's room. R84's 11/1/24 nursing progress note completed by V16 (Assistant Director of Nursing/ADON) shows R84 refused to have a full body assessment done after the incident, but she reported she was having pain to her left lower extremity and right arm. On 1/15/25 at 11:43 AM, V14…

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 its abuse policy for 1 of 6 residents (R166) reviewed for abuse policy and procedures in the sample of 10. The findings include: R166's face sheet shows he was admitted to the facility on [DATE], and is a [AGE] year old white male. R166's criminal history background check shows it was initiated on 5/28/24, however, R166's race was listed as black on the report, and it shows the results listed as IN PROCESS. A second Criminal History Report, dated 6/27/24, shows R166 has a HIT and has had prior arrests, which included domestic battery. A copy of R166's fingerprint search and risk analysis report was requested and not provided by the facility. On 1/15/25 at 2:08 PM, V1 (Administrator) and V9 (Assistant Administrator) said there was a mix up and corporate had not forwarded the results of R166's Criminal History Report that showed R166 had a HIT, so fingerprints were never ordered for R166. V1 said she was not aware of R166 having a HIT on his…

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 meaningful activities to dementia residents to 2 of 32 residents (R70, R111) reviewed for activities in the sample of 32. The findings include: 1. R70's activity careplan, dated 12/2/24, showed, (R70) is a part of the AOW (activity on wheels) program. (R70) has a pleasant demeanor and is an active participant in both group activities and independent activities. She enjoys playing bingo, puzzles, brain games, and doing arts and crafts . On 1/13/25 at 10:36 AM, R70 was in bed. R70 said there was nothing to do, it gets boring. All we do in our room is to stare at each other. At 11:00 AM, 1:00 PM, and 2:00 PM, R70 remained in bed. No noted activities were offered. On 1/14/25, at 10:00 AM, R70 was sitting in her wheelchair. An overhead announcement of, Music activity on 2nd floor. When asked if she wanted to go to the Music Activity, R70 said she does not want music. At 11:00 AM, R70 was in bed. On 1/14/25 at 11:06 AM, V8 (Activity Assistant) said she offered R70 juice yesterday from the AOW. V8 said today…

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

Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion (ROM) was evaluated for a brace and received ROM exercises for 1 of 4 residents (R63) reviewed for ROM in the sample of 32. The findings include: R63's Care Plan, with an initiated date of 10/12/22, showed R63 would benefit from an active assisted ROM program 3-7 days a week. R63's Order Summary Report, dated 1/15/25, showed an order for restorative nursing to evaluate R63's left wrist/finger contractures for the use of a splint or any other support to prevent further contractures. The order was dated 11/26/24. R63's Progress Note entered by a Nurse Practitioner, dated 11/26/24, showed restorative advised to evaluate resident for possible use of a splint or other appropriate device to prevent further contractures of the left wrist and finger. On 1/14/25 at 11:20 AM, R63 was in bed. R63's left wrist was bent/contracted in the flexed position at about 90 degrees. R63's left index finger was straight. R63 was asked if he can move his left wrist and index finger, 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 ensure residents were supervised during medication administration for 2 of 32 residents (R16, R42) reviewed for pharmacy services in the sample of 32. The findings include: 1. On 1/13/25 at 10:35 AM, on R16's bedside stand was a small orange pill. R16 was asked what the medication was and he responded it was Adderall from his morning medication he did not take because he didn't want to stimulate his system more. R16 said his nurse (V20) had brought his pills in that morning. R16's Physician Order Summary (POS) shows he has an active order for Adderall 20 milligrams (mg.) to be given two times a day. R16's POS does not show an order to self-administer oral medications. On 1/13/25 at 11:46 AM, V20 (Registered Nurse/RN) said no residents on the unit can self-administer their own oral medications (pills); nurses have to watch the residents take their medication. V20 said she had taken in R16's medication that morning, and she had thought he had taken the medication. 2. On 1/14/25 at 10:10 AM, R42 had 2 plastic…

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 staff used the required personal protective equipment (PPE) when entering a contact isolation room, and failed to have signs up identifying residents on isolation for COVID-19. This applies to 3 of 32 residents (R78, R54, and R148) reviewed for infection control in the sample of 32. The findings include: 1. On 1/13/25 at 9:52 AM, there was a sign on the door frame of R78's room indicating R78 was on contact isolation. On 1/13/25 at 9:54 AM, V3 (Certified Nursing Assistant - CNA) entered R78's room. V3, without having gloves or a gown on, repositioned R78 in bed, rearranged R78's pillow that was under R78's head, and adjusted the blankets R78 was using. On 1/14/25 at 1:21 PM, V23 (CNA) said gowns and gloves are the required PPE that staff are to put on before entering a contact isolation room. R78's Care Plan, printed on 1/14/25, showed R78 was on isolation for extended-spectrum beta-lactamases (ESBL) of the urine. R78's Medication Administration Record for January 2024 showed R78 was being treated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess a resident over [AGE] years of age for their pneumonia vaccination and failed to assess a resident for the influenza vaccination. This applies to 3 of 5 (R27, R23, R17) residents reviewed for vaccinations in the sample of 32. The findings include: R27's Clinical - Immunizations document, dated 1/15/2025, lists the resident as [AGE] years of age with an influenza administration date of 1/14/2025. R23's Clinical - Immunizations document, dated 1/15/2025, lists the resident as [AGE] years of age with an Prevnar 13 dose administered on 4/21/2024. R17's Clinical - Immunizations document, dated 1/15/2025, lists the resident as [AGE] years of age with a Pneumovax Dose 1 administered on 6/17/2018. On 1/15/2025 at 10:34AM, V24 Infection Control Preventionist (ICP) Nurse stated R27's influenza vaccine should have been offered at the start of flu season. V24 said she tried to reach out to R27's Power of Attorney (POA) and was unable to get a hold of them.…

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

Based on observation, interview, and record review, the facility failed to ensure a resident was free from verbal abuse for 1 of 5 residents (R4) reviewed for abuse in the sample of 11. The findings include: The facility's Interview with R4 shows, (R4) went out in hall to look for someone because (R5's) machine was beeping. I talked to a tall black lady with short red hair. I told her that my brothers' concentrator was beeping and that I put my own pulse ox (oxygen saturation) on him and his oxygen was now 93% and it was going down. (V12) walked by me and yelled 'Fk this, I am Fking tired of this, I am Fking done.' I went back to my room to see how (R5) was. The machine was still amber and red so I went to nurses station to see who was in charge, it was (V9, Licensed Practical Nurse/LPN) and (V8, RN). I was telling them what was happening and then (V12) came around the corner and yelled at me 'You and your brother keep threatening me!' (V12) kept walking towards me yelling and threatening me. I yelled back at him and said, 'This is you last fking day, you can't threaten me!'…

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 was free from physical abuse. This applies to 1 of 8 residents (R1) reviewed for abuse in the sample of 8. The findings include: R1's physical incident report, dated 5/11/24, shows, Nursing description: (R1) wandered into another residents room and started taking the food off trays of both occupied resident. Resident was pushed by one of the occupants and fell to floor on Rt (right) side causing small laceration to rt eye brow area . R1's incident report does not show who the resident was that pushed R1. The facility's preliminary 24 hour incident investigation report, dated 5/11/24, shows an allegation of physical abuse with R1 and R2. On 5/20/24 at 9:41 AM, R1 had just got done using the restroom and was washing her hands. She had a 2 inch (approximately) scabbed over laceration on her right eyebrow. There was a faded yellow and green bruise to the right area of her eyebrow and forehead. This surveyor asked her what…

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 assess/monitor a resident for 72 hours after having a fall and hitting their head. This applies to 1 of 3 (R4) residents in the sample of 8 reviewed for quality of care. The findings include: On 5/20/2024 at 9:36AM, R4 was observed in her room walking around with yellow/green and blue discoloration on approximately 50% or more of her forehead. On 5/20/2024, V2, Director of Nursing (DON), said on 5/8/2024, R4 had a fall in front of her bathroom door. V2 said R4 said she hit her head on the door. V2 said she was in charge of investigating the fall after it occurred for [R4]. V2 said vital signs and neuro checks should be done for 72 hours after a fall every shift, in the post fall occurrence charting. V2 said the post fall occurrence charting for the following 72 hours was not completed for R4. R4's fall report, dated 5/8/2024, states nursing supervisor was doing rounds and heard a noise come from the resident's room. R4 was seen sitting in front of her bathroom holding her forehead. Resident stated the door hit her 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 ensure a resident room was free from pests for 1 of 10 residents reviewed for pest control (R3) in the sample of 10. The findings include: On 5/6/24 at 9:17 AM, V5 (Licensed Practical Nurse/LPN) said there is a problem with roaches in the facility and R3's room is pretty bad. V5 stated, They claim to be spraying but it doesn't seem to be working. On 5/6/24 at 9:32 AM, R4 was sitting in the room of R3 while he was at therapy. R4 said there is a big problem with cockroaches in the room. She showed the surveyor a hole in the bottom wall of the bathroom behind the toilet where the baseboard was also missing, and said roaches come into the room from the hole in the wall. When R3's mini refrigerator and dresser were pulled away from the wall, assorted sizes of bugs scattered up the walls. As R4 and this surveyor were talking she said, Look there's one on his dresser. A large bug was crawling on the blanket that was sitting on top of the dresser and the same bugs were also seen in the closet of the room. On 5/6/24…

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

Based on observation, interview, and record review, the facility failed to ensure a bulk bin scoop was free of caked-on debris, and that it was cleaned and sanitized in a manner to prevent cross contamination. This has the potential to effect all residents residing in the facility. The findings include: On 12/11/23 at 11:37 AM, a bulk bin scoop stored inside the flour bulk bin had flour caked on the food contact surfaces. V8 (Food Service Director), present during the observation, said the standard of practice is to wash and sanitize the scoop once a day. Using a scoop with caked on flour can lead to cross contamination and bacterial growth. Facility provided Cleaning Instructions: Ingredient Bins policy, no date, states, . 8. Clean and sanitize ingredient scoops in dishwashing machine regularly. The Centers for Medicare and Medicaid Services 671 form, dated 12/11/23, shows 184 residents reside in the facility. Food and Drug Administration 2022 Food Code states, 4-6 Cleaning of Equipment and Utensils . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, 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 ensure residents who are dependent on staff for activities of daily living received assistance with incontinence care, oral, and nail care. This applies to 4 of 35 (R333, R130, R88, R41) residents reviewed for activities of daily living. The findings include: 1. R333's face sheet shows he is a [AGE] year old male, with diagnoses including multiple sclerosis, pressure ulcer of sacral region stage 3, pressure ulcer left buttock unstageable, pressure ulcer of right heel unstageable, functional quadriplegia, encounter attention to tracheostomy, and gastrostomy. On 12/11/23 at 11:54 AM, V11 and V12 (Wound Nurses) were in the room to provide wound care. V12 pulled back R333's top bed sheet; large amounts of soft stool were seeping out of his incontinent brief, and stool was on the bottom bed sheet. V12 notified V22 (Certified Nursing Assistant-CNA) to assist with incontinence care. V22 removed R333's heavily soiled incontinent brief; large…

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 residents receiving a puree diet with smooth consistency puree broccoli. This applies to 11 of 11 (R55, R16, R76, R232, R57, R20, R32, R33, R22, R160, and R483) residents reviewed for puree diets in the sample of 35. The findings include: Facility provided Diet Type Report, dated 12/12/23, shows R55, R16, R76, R232, R57, R20, R32, R33, R22, R160, and R483 receive a pureed textured diet. On 12/12/23 at 11:17 AM, V17 (Assistant Kitchen Manager) said a puree texture should be similar to a good mashed potato, or like baby food. On 12/11/23 at 1:37 PM, the facility provided a test tray of pureed broccoli, pureed chicken, and pureed stuffing. The pureed broccoli had a grainy texture, which elicited chewing to swallow. On 12/11/23 at 1:37 PM, V8 (Food Service Director) said, The broccoli is grainy. On 12/13/23 at 10:00 AM, V7 (Diet Technician) said, If a resident receiving a pureed diet receives the incorrect consistency then that resident is at risk for choking and aspiration. Facility Pureed Food…

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 put on isolation precautions, which applies to 4 of 35 residents (R382, R175, R176, R6) reviewed for infection control in a sample of 35. The findings include: 1. R382's Facility Assessment, dated 10/10/23, showed R382 to be a [AGE] year old male resident with severe cognitive deficit who required total care from staff. R382's Medication Administration Record for 12/2023 showed R382 was started on Vancomyacin oral suspension of 50 milligrams (mg)/milliliter (ml). to be given 2.5ml (150 mg) enterally four times a day for C-diff prophylaxis for 10 days. On 12/11/23 at 10:00 AM, R382's room had a enhanced barrier precautions sign and cart outside room. On 12/12/23 at 10:00 AM, R382 had liquid stool coming out of his brief during a dressing/wound check. V12 Wound nurse stated R382 has had liquid stool for a while. On 12/13/23 at 9:30 AM, V3 Infection Control Preventionist stated, (R382) was put on oral Vancomyacin for…

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

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to standards of practice for 1 of 35 residents (R65) reviewed for pharmacy services in the sample of 35. The findings include: On 12/11/23 at 9:56 AM, R65 was in bed asleep. On her overbed table which was pushed away down to the foot of her bed, was a plastic medication cup with a intact white pill inside with markings identifying it as G 12. At 1:19 PM, R65 was awake and sitting on the side of her bed. The white pill was now out of the plastic container and was only half there. This surveyor asked R65 if she knew what the pill was and she responded, They left it in here this morning; I am not sure what it is; I took half. On 12/11/23 at 1:33 PM, V9 (Licensed Practical Nurse) said she was the nurse who gave R65 her medication and she thought she saw her take it. V9 confirmed there are no residents on the 4th floor, which is a memory care floor, that have orders to self-administer their medications. V9 went to R65's room and identified the pill as Metformin…

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

Based on observation, interview, and record review, the facility failed to ensure a residents bedding and privacy curtain were clean and changed when soiled to promote a homelike environment for 1 of 35 residents (R41) reviewed for homelike environment in the sample of 35. The findings include: On 12/11/23 at 10:42 AM, R41 was lying in bed. The fitted sheet underneath him had a very large yellow stain on the right side at the pillow level that appeared to be spilled liquid. At the same height and side by his pillow was another stain that was pink in color. On the sheet to the left side of the pillow was pieces of what appeared to be dried food. Down by his mid section on the middle of the bed was a dried brown stain that appeared to have been wiped off the sheet. The top sheet on his bed also had the same brown dried patch consistent with the bottom sheet. On the floor next to his bed was dried food and crumbs. His overbed table was very sticky with what appeared to be spilled liquid and a used mustard packet. The privacy curtain next to his bed was pulled and was also very dirty…

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 meaningful activities for a resident with Dementia. This applies to 1 of 35 residents (R94) reviewed for activities in the sample of 35. The findings include: Throughout the survey on 12/11/23 and 12/12/23, R94 was observed either sitting in his room in his wheelchair next to his bed, or lying in his bed. There was no television on in R94's room and no music playing for R94 to listen to. R94 was not engaged in any activity. On 12/13/23 at 8:56 AM, V5 (Activity Assistant) stated, (R94) likes coffee. He asks for coffee or items off the snack cart. He only has one hand, so I used to color with him. Most of the time when we ask him if he wants something, he says no. V5 also explained the facility has an activity program known as AOW (Activity on Wheels), which means they take a cart around to each resident's room and offer them snacks and individual activities like puzzles, magazines and coloring books from the cart. V5 stated R94 was part of the AOW Program. R94's care plan, last revised on 2/6/23,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify, assess, and provide treatment to a resident's heel prior to developing a deep tissue injury, and failed to ensure a resident's treatment dressings were changed. This applies to 2 of 7 residents (R125, R333) reviewed for pressure ulcers in the sample of 35. The findings include: 1. R125's face sheets shows she is [AGE] year old female, with diagnoses including monoplegia of upper limb following cerebral infarction affecting right dominant side, aphasia following cerebral infarct, dementia, bipolar (disorder), and spinal stenosis. R125's Braden Score, dated 11/26/23, shows she is at risk for developing pressure injuries. On 12/11/23 at 10:02 AM, R125 was observed lying in in bed on a regular mattress. At 10:15 AM, V24 (Certified Nursing Assistant/CNA) repositioned R125 on her left side. She said, (R125) is really stiff, she cannot roll on her own. Staff have to reposition her. On 12/12/23 at 1:10 PM, R125 was observed sitting 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's indwelling catheter bag was maintained off the floor to prevent infection. This applies to 1 of 9 residents (R333) reviewed for urinary catheters in the sample of 35. The findings include: R333's face sheet shows he is a [AGE] year old admitted on [DATE], with diagnoses including multiple sclerosis, functional quadriplegia, benign prostatic hypeplasia with lower urinary tract symptoms, encounter attention to gastrostomy, and tracheostomy. On 12/11/23 at 11:06 AM, R333's urinary catheter bag and tubing was observed lying on the floor with moderate amount of urine in the bag and in the tubing. At 11:51 AM, R333's urinary catheter bag remained on the floor. V22 (Certified Nursing Assistant-CNA) was in the room providing incontinence care. She was standing on the right side of the bed where the urinary catheter bag was located on the floor. V22 did not pick up R333's urinary bag from the floor. She continued to provide…

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 nutritional interventions (weekly weights) were completed for a resident with significant weight loss. This applies to 1 of 8 residents (R148) reviewed for weight loss in the sample of 35. The findings include: R148's face sheet shows he has diagnoses including vascular dementia. R148's active care plan, initiated on 4/26/22, shows he is at risk for compromised nutritional status and has on going significant weight loss. The last update to his care plan shows he had a significant 5.9% weight loss in 1 month and 10% in 6 months. R148's weight summary shows on 5/12/23 he weighed 160 pounds (lbs.), which was trending downward monthly and on 11/9/23 he weighed 144.2 lbs. a 15.8 lb 9.88% weight loss in 6 months. On 10/10/23 he weighed 153.2 and on 11/9/23 he weight 144.2 which is a 9.0 lb. 5.87% weight loss in 1 month. R148's dietary note completed by V16 (Dietician) on 11/16/23 shows R148 had triggered for significant weight loss for a 5.0% loss in 30 days, and a 10.0% loss in 180 days. V16 made a note to complete…

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 administer intravenous medications according to standard of practice to 1 of 4 residents (R175) reviewed for medications in the sample of 35 R175's Physician Order Sheet (POS), dated 12/2023, shows R175 has diagnoses of osteomyelitis, diabetes, and arthritis. The same POS shows R175 has an order for intravenous (IV) antibiotic therapy (Cefazolin Sodium Injection Solution Reconstituted 2 gram intravenously (IV) every 8 hours for osteomyelitis (bone infection) bacteremia, and septic arthritis. R175's Hospital Transfer Form, dated 12/8/23, shows R175 has a PICC line (Peripherally Inserted Central Catheter) to his left arm surgically inserted by the hospital on [DATE]. On 12/11/23 at 10:31 AM, R175 was in bed. R175's PICC line to his left upper arm was intact. R175 had IV antibiotics being administered through his PICC line. V4 (License Practical Nurse-LPN) entered the room, turned off the IV, disconnected the IV tubing from the PICC line…

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 a Dietitian's recommendation for weekly weights for a resident with significant weight loss. This applies to 1 of 3 residents (R1) reviewed for weight loss in the sample of 3. The findings include: R1's admission Record showed R1 was an [AGE] year old female with diagnosis of severe protein-calorie malnutrition. The same document showed R1 was admitted to the facility on [DATE], and discharged from the facility on 11/29/23 On 12/6/23 at 10:00 AM, V5 (Wound Care Nurse) described R1 as, frail and, really thin. R1's Weight Summary documentation showed on 10/4/23 R1 weighed 92.2, pounds and on 11/2/23 weighed 84 pounds. A significant weight loss of 8% in one month. On 12/6/23 at 11:43 AM, V3 (Dietitian) said R1 had significant weight loss. V3 said on 11/7/23, she recommended weekly weights to be done. V3 said weekly weights are done to monitor for a downward trend. V3 said when she looks for a resident's weight she looks in the Weight Summary…

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 residents room was in a sanitary condition. This applies to 1 of 8 residents (R2) reviewed for home like environment. The findings include: R2's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE]. R2's diagnosis include hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, nontraumatic intracerebral hemorrhage in cerebellum, and dysphagia. On 10/18/23 at 10:22 AM, R2 was observed in his room. A yellow caution floor wet sign was in his room. R2 said when he was admitted to the facility on Saturday, his room was so dirty his wife and V20 (daughter) cleaned the room. There was brown and red spots on the bed's side rail and a foul odor. On 10/19/23 at 9:47 AM, V20 (R2's daughter) said R2 was admitted to the facility on [DATE] about noon. She and came to the facility about 6:00 PM with R2's wife. The room was dirty, it smelled like urine and there was red and brown spots on 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 was safely transferred. This applies to 1 of 3 residents (R2) reviewed for safety in the sample of 8. The findings include: R2's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE]. R2's diagnosis include hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, nontraumatic intracerebral hemorrhage in cerebellum, and dysphagia. On 10/18/23 at 10:22 AM, R2 was observed lying in his bed. He said his right leg is heavy and he does not have control over his body. His right arm was drawn into his chest. He said there's been a lot things that have happened at the facility that he is not happy with. He said on 10/14/2,3 he was transferred by one staff member in a rushed, unsafe manner. On 10/18/23 at 10:17 AM, V4 (Social Worker) said, A staff member told me (R2 was upset. I talked to (R2) and he said he was upset in the manner he was transferred by (V11, Certified…

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.