La Bella of Woodstock

Based on observation, interview and record review the facility failed to ensure residents' non-invasive ventilation machine Continuous Positive Airway Pressure (CPAP) masks fit securely on residents faces to provide the prescribed treatment for their obstructive sleep apnea for 2 of 3 residents (R1, R2) reviewed for respiratory care in the sample of 4.The findings include:1.R1's physician order dated 12/12/25 showed an order for R1 to be placed on CPAP at night when sleeping due to his diagnosis of obstructive sleep apnea. On 1/20/26 at 8:54 AM, R1 was awake, lying in bed. A CPAP machine with attached tubing and face mask was noted on a table by the foot of R1's bed. The CPAP machine and equipment appeared clean and unused. R1 stated he had not used his CPAP at night for months because the mask doesn't fit. It leaks air and blows into my eyes. R1 stated he told nursing and a pulmonology nurse practitioner about his ill-fitting mask, but nothing had been done about it. R1's Health Status note dated 12/10/25 showed R1 was seen and examined by V5 Nurse Practitioner (NP). The note…

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 wore a beard guard/net while handling/serving food. This has the potential to affect all 73 residents in the facility.The findings include: The facility's Facility Data Sheet dated 12/19/25 shows 73 residents reside in the facility.On 12/19/25 as the lunch meal was being served/plated in the dining room at 12:08 PM, V15, Cook, was observed to have a beard and was not wearing a beard guard as he plated the residents' meals.On 12/19/25 at 12:30 PM, V4, Dietary Manager, stated a beard guard is required if the (facial) hair is more than an inch long. The facility's Dietary Policies and Procedures Dress Code Policy (not dated) shows beard nets should be used for employees with facial hair.

Based on interview and record review, the facility failed to ensure a resident had privacy during personal activities of daily living for 1 of 4 residents (R2) reviewed for resident rights in the sample of 4. The findings include:On 12/19/25 at 8:44 AM, R2 said about a week and a half ago she was getting ready to get up and V3, Maintenance Director, told V6 and V7, Housekeeping, to do a deep cleaning of her room. R2 said the three of them all said she was getting up, but V3 told them to do it anyways. R2 said they closed the curtains while the CNA (certified nursing assistant), V8, was getting her ready (cleaned and dressed), but she still felt uncomfortable. R2 said V6 said R2 is getting up and asked if they could wait until she was done, but V3 said to do it anyway. R2 said she contacted the Ombudsman and asked him to file a formal complaint.On 12/19/25 at 9:58 AM, V6 said they clean residents' rooms when residents are in there, but they absolutely do not clean while residents are getting personal cares. V6 said about two weeks ago, V3 told her to clean a resident room. V6 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 staff performed hand hygiene after touching their face/nose and handling resident food for 1 of 4 residents (R4) reviewed for infection control in the sample of 4.The findings include: On 12/19/25 at 12:22 PM, V11, Certified Nursing Assistant (CNA), was sitting in the dining room feeding R4. V11 had her left hand over her mouth, resting her head on her left hand as she was feeding R4. V11 then rubbed her hands together and ran them over her nose. R4 asked for more bread and V11 went to the serving counter and got more garlic bread and brought it to R4. V11 did not wash her hands or perform hand hygiene before delivering the bread to R4.On 12/29/25 at 12:44 PM, V4, Dietary Manager, stated staff should not touch their face/nose and deliver food to the resident without washing or sanitizing their hands first; it's not sanitary.The facility's Hand Washing Policy (not dated) shows staff should wash their hands before handling food. Staff should wash hands to remove contamination after touching bare human…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from misappropriation for one of four residents (R2) reviewed for misappropriation in the sample of four. This past noncompliance occurred from August 14, 2025-August 14, 2025.Findings include:R2's admission Record dated August 25, 2025, shows he was admitted to the facility on [DATE], with diagnoses including hemiplegia, chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder.R2's Care Plan initiated July 17, 2025, shows R2 is functioning at an independent level in his leisure pursuits. He is alert, oriented and able to express his needs, desires, and opinions. R1's admission Record dated August 25, 2025, shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellites II, syphilis, adjustment disorder, schizophrenia, ataxia, and depression.R1's Care Plan initiated August 15, 2024, shows R1 displays behavioral symptoms that are manifested by always asking peers,…

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 (R11) was free from restraints. This applies to 1 of 1 resident's reviewed for restraints in the sample of 11.The findings include:R11's electronic face sheet printed on 8/6/25 showed R11 has diagnoses including but not limited to chronic respiratory failure, heart failure, history of falls, bipolar disorder, and unsteadiness on feet.R11's facility assessment dated [DATE] showed R11 has moderate cognitive impairment and does not utilize restraints.On 8/6/25 at 12:15PM, V12 (Licensed Practical Nurse) assisted R11 into his bed and put the half side rail down on the left side of the bed. (The bed rail is positioned so it covers the middle of the bed and R11's bed is pushed against the wall on the right side).On 8/6/25 at 12:17PM, V13 (Certified Nursing Assistant) stated, We always put the siderail down for (R11) to help with positioning and so he knows to ask for help to get up. If he did try to get up, he would have to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 residents (R8,R11) had fall prevention measures in place. This applies to 2 of 3 resident's reviewed for fall prevention in the sample of 11.The findings include:1) R8's electronic face sheet printed on 8/6/25 showed R8 has diagnoses including but not limited to metabolic encephalopathy, schizoaffective disorder, anxiety disorder, restlessness and agitation, and major depressive disorder.R8's facility assessment dated [DATE] showed R8 has severe cognitive impairment, has not had any falls since admission to the facility, and does not utilize alarms while in her bed or chair.R8's fall risk assessment dated [DATE] showed R8 is a high fall risk.The facility's Incident Report Log as of 8/5/25 showed R8 has experienced 11 falls within the past 3 months at the facility.On 8/5/25 at 12:53PM, R8 was in her bed laying on her right-side sleeping. R8's alarm clip was hanging on the mattress next to her bed on the floor and was not clipped…

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 have evidence that R4's alleged allegations were thoroughly investigated for 1 of 6 residents (R4) reviewed for abuse in the sample of 6. The findings include:On 07/23/2025 at 12:22PM, R4 was lying in bed on his left side with eyes closed. On 07/23/2025 at 12:22PM, R4 said, the staff have been giving me a hard time when I call for help. I went to the bathroom; the staff gave me a hard time due to them getting off work soon. I told the administrator. V5 CNA's-Certified Nursing Assistant told me she did not want to come in my room to provide care. I told her to shut her mouth. She started walking down the hallway cussing. I watch the security video with the administrator yesterday. It showed V5 CNA walking down the hallway. The video did not have sound at the time, V1 may not have turned the volume on.On 07/23/2025 at 12:30PM, V1 Administrator was not in the facility.On 07/28/2025 at 8:37AM, V1 Administrator said, I will call you back. On 07/28/2025 at 11:19AM, V4 Nurse Consultant said, V1 Administrator has been…

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 R1 did not leave the facility unsupervised, this applies to 1 of 6 residents (R1) reviewed for supervision in the sample of 6.The findings include: R1'S Minimum Data Set, dated [DATE] shows, R1 has a moderate cognitive impairment. On 07/23/2025 at 9:00AM, R1 was lying in bed. R1 sat up on the side of the bed. R1 then moved her wheelchair into position, engaged the left and right brake, stood to her feet, and sat herself down in the wheelchair. On 07/23/2025 at 9:00AM, R1 said, I can move myself in my wheelchair using my arms and legs. I am not able to move quickly. On 07/23/2025 at 11:30AM, V4 Nurse Consultant said, after R1 was found outside we initiated 1:1 monitoring and then applied a bracelet to her arm. When R1 gets close to the doors that lead outside an alarm will go off. On 07/23/2025 at 12:53PM, V2 DON-Director of Nursing said, the front door alarm went off around 9:30PM. There is no receptionist at the front door during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's funds were safeguarded and free from misappropriation. This applies to 2 of 3 residents (R4, R5) reviewed for misappropriation in the sample of 5. The findings include:(1.) R4's Minimum Data Set (MDS) dated [DATE], shows that R4 is cognitively intact.On 7/14/25 at 9:06 AM, R4's bedside drawer had a latch attached, allowing the top drawer to be locked by a pad lock. There was not a pad lock on the drawer at this time. The back panel of R4's bedside drawer was originally fastened with nails. However, at this time, the back panel of R4's bedside drawer was still half off, allowing access into R4's bedside drawer through the back. On 7/14/25 at 9:06 AM, R4 said after returning from a day out on pass with family on a Saturday in June, R4 noticed that R4's bedside drawer had been pulled away from the wall and a plastic shoebox containing compact discs and a compact disc player was on the floor behind the bedside drawer. R4 thought nothing…

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

Based on interview and record review the facility failed to report an allegation of abuse to the state agency. This applies to 3 of 3 residents (R1, R4, R5) reviewed for abuse in the sample of 5. The findings include:(1.) On 7/14/25 at 12:00 PM, R1 said approximately three months ago, R1 lost his wallet in the facility. R1 stated the facility found the wallet in laundry, but when it was returned, R1 noticed there was a $100 bill missing from inside the wallet. Nothing else was removed or misplaced from R1's wallet. R1 said everybody knew the money was missing, including V10 (Social Services Director). R4 requested the facility to not contact the local police or R4's husband regarding the missing money.On 7/14/25 at 1:38 PM, V1 (Administrator) said he believes the incident regarding R1's lost money and wallet happened prior to V1 started working at the facility in April. V1 said V1 heard about the incident a few weeks ago when V1 heard staff talking about the incident in the hallway. V1 states he spoke with R1 and laundry employees, but V1 never completed a formal investigation and…

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

Based on interview and record review the facility failed to ensure allegations of misappropriation were thoroughly investigated. This applies to 3 of 3 residents (R1, R4, R5) reviewed for abuse in the sample of 5. The findings include:(1.) On 7/14/25 at 12:00 PM, R1 said approximately three months ago, R1 lost R1's wallet. R1 said it was later found in the laundry and was returned to R1, but was missing a $100 bill. R1 notified staff of the missing money, but R1 said R1 has not been reimbursed for the missing money. Facility resident council minutes for April 2025 shows that a resident mentioned they were missing money during laundry. The resident council minutes also show that R1 was in attendance for the April meeting. (2.) On 7/14/25 at 9:06 AM, R4 said after returning from a day out on pass with family on a Saturday in June, R4 noticed that R4's bedside drawer had been pulled away from the wall and a plastic shoebox containing compact discs and a compact disc player was on the floor behind the bedside drawer. R4 thought nothing of it that evening and asked staff to help pick 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.

Based on observation, interview and record review the facility failed to ensure a resident was transferred safely using a mechanical lift for 1 of 3 residents (R1) reviewed for safety in the sample of 5.The findings include:On 7/14/25 at 10:05 AM, R1 was sitting in his wheelchair in the dining room. R1 had a raised discolored area on his right posterior forearm. R1 said that he had a fall while being transferred from his bed to the wheelchair with a mechanical lift. R1 said that there was only one aide in the room when he fell. R1 said that the lift tipped over and landed on the aide. R1 said that he went to the hospital right afterwards and got an X-ray of his right arm and a scan of his head. R1's Nurse Practitioner Note dated 7/1/25 at 11:40 AM shows, Patient seen and examined today per nursing request for a witnessed fall. Per CNA (Certified Nursing Assistant), patient being lifted by Hoyer (mechanical) lift then sling tipped to the side and patient fell on the floor. DON (Director of Nursing) reports patient had loss of consciousness and awoke only after stimuli, shaking…

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 needs were accommodated by not assisting a resident with obtaining a replacement motorized wheelchair for one of five residents (R1) reviewed for accommodation of needs in the sample of five.The findings include:R1's admission Record shows he was admitted to the facility on [DATE] with diagnoses including hemiplegia affecting right dominant side, major depressive disorder, anxiety disorder, restless legs syndrome, nicotine dependence (cigarettes), and chronic venous hypertension with ulcer of right lower extremity.R1's Care Plan revised on January 11, 2025 shows R1 has been noted with behaviors of self-propelling his wheel chair backwards in order to get to his destinations. R1's Care Plan initiated November 18, 2024, shows R1 has limited physical mobility, the resident is non weight bearing and provide supportive care, assistance with mobility as needed, and document assistance as needed. R1's provider visit note done…

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 an as needed psychotropic medication order had a stop date for 4 of 5 residents (R49,R175,R16,R54) reviewed for chemical restraints in the sample of 20. The findings include: 1.R49 Physician's Order shows, lorazepam 0.5 milligram give 1 tablet by mouth every 4 hours as needed for anxiety. Start date 04/28/2025, no stop date or duration provided. 2.R175 Physician's Order shows, lorazepam 1 milligram give 1 tablet by mouth every 8 hours as needed for anxiety/restlessness/agitation. Start 05/22/2025, no stop date or duration provided. 3. R54's Face Sheet printed on 6/3/25 showed R54 had a diagnosis of anxiety. R54's Order Summary Report printed on 6/3/25 showed an order for lorazepam (anxiety psychotropic medication) to be given as needed. The order had a start date of 5/13/25. There was no duration or stop date for the medication. 4. R16's Face Sheet printed on 6/3/25 showed R16 had a diagnosis of anxiety. R16's Order Summary Report showed an order for lorazepam to be given as needed. The order had a start date of…

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

Based on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity while being fed for 1 of 20 residents (R41) reviewed for resident rights in the sample of 20. The findings include: On 6/2/25 at 11:49 AM, V11, Certified Nursing Assistant (CNA) was standing up feeding R41 lunch in the dining room. On 6/3/25 at 12:37 PM, V2, Director of Nursing (DON), said when staff is feeding a resident, they should sit down with the resident at eye level and have a conversation with the resident. V2 said it's important to provide social interaction and make the interaction more pleasant. The facility's Promoting/Maintaining Resident Dignity During Mealtimes Policy (implemented 5/2025) shows it is the practice of the facility to treat each resident with respect and dignity and care for each resident in a manner that enhances her quality of life. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. All staff will be seated while feeding a resident.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents fingernails were clean and trimmed for 2 of 20 residents (R47, R27) reviewed for Activities of Daily Living care in the sample of 20. The findings include: 1.) On 06/02/25 at 1:34PM, R47 was sitting in the hall. R47 had scratches to his forehead, right eye orbit, and left temple area. R47's right middle, ring, and small fingers was contracted. R47's fingernails extended past the tip of his fingers. On 06/02/25 at 1:34PM, R47 was asked, do you like your fingernails long? R47 responded, No. On 06/02/25 at 1:40 PM, V10 CNA-Certified Nursing Assistant said, when R47 becomes anxious he tends to scratch himself, he has scratches all over his body. R47's Minimum Data Set, dated [DATE], shows, R47 is dependent on staff for personal hygiene. Staff does all of the effort. Resident does none of the effort to complete the activity. 2.) On 6/2/25 at 9:45 AM, and again on 6/3/25 at 8:58 AM, R27 was observed and had very long nails with…

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

Based on observation, interview, and record review the facility failed to ensure a resident with congestive heart failure (CHF) had weights done as ordered for 1 of 2 residents (R14) reviewed for quality of care in the sample of 20. The findings include: R14's Face Sheet printed on 6/3/25 listed heart failure as a diagnosis. R14's Physician Progress Note dated 5/25/25 showed R14, .suffers from congestive heart failure. The same note showed R14 had no worsening of lower extremity edema. On 06/02/25 at 11:12 AM, R14 was sitting at the edge of the bed. R14's pant legs ended mid shin. R14 did not have socks on and was wearing slippers. R14 had what appeared to be edema to both legs. R14's Order Summary Report printed on 06/03/25 showed an order for daily weights and to notify the health care provider if there was an increase of more than two pounds and the weights were being done for edema. The order had a start date of 5/5/25. R23's Medication Administration Record for May 2025 showed a recorded weight on 5/6/25, 5/20/25, and 5/27/25. R23's Monthly Weight Report printed on 6/3/25…

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 pressure relieving interventions were in place for a resident at risk for pressure injuries for 1 of 2 residents (R54) reviewed for pressure injuries in the sample of 20. The findings include: R54's Braden Scale for Predicting Pressure Score Risk done on 04/11/25 showed R54 was at risk for developing pressure injuries. R54's Order Summary Report printed on 6/3/25 showed an order for and air mattress while in bed. On 06/02/25 at 09:12 AM and at 2:05 PM, R54 was in bed. Hanging on the foot of the bed was an air mattress pump. The power switch was not lit up and in the off position. On 06/03/25 at 08:13 AM and at 11:47 AM, R54 was in bed. Hanging on the foot of the bed was air mattress pump. The power switch was not lit up and in the off position. On 06/03/25 at 11:56 AM, V13 (Certified Nursing Assistant) was asked by the survey if R54's air mattress pump was on. V13 looked at R54's pump and said the air mattress pump was off. V13 said the air mattress pump is an intervention to help prevent pressure…

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 and assess a resident's contracted left hand. The facility also failed to ensure a resident's wheelchair was the appropriate fit to allow him to sit comfortably in the chair. This applies to 1 of 6 residents (R37) reviewed for range of motion and mobility in a sample of 20. The findings include: On 6/2/25 at 10:17 AM R37 stated that the facility took his wheelchair and gave him a high back wheelchair that he can't propel himself in and is not comfortable and he gets stuck in the hallway for long periods of time. R37 stated he did not know why they changed his wheelchair, but he does not like this one. On 6/3/25 at 9:19 AM R37 was transferred from his bed to his high back reclining wheelchair using a mechanical lift. R37's left hand was in a closed position with his fingernails pressing into the palm of his hand. R37 was asked if he could straighten his fingers on his left hand and R37 stated, I used to have a ball that I would hold…

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 dietitian's recommendations were implemented and failed to ensure a dietary supplement was given to a resident. This applies to 2 of 5 residents (R23 and R27) reviewed for weight loss in the sample of 20. The Findings include: 1.) R23's Weight Summary report printed on 6/4/25 showed the following weights: 173.2 pounds on 4/17/25, 169 pounds on 5/14/25, and 167.6 pounds on 6/3/25. R23's Nutrition/Dietary Note dated 4/17/25 indicated the dietitian recommended to add double portions to breakfast with the goal of stabilizing R23's weight and allowing weight gain. R23's Nutrition/Dietary Note dated 5/22/25 indicated the dietitian recommended adding a house supplement to be given twice a day. R23's Order Summary Report printed in 6/3/25 did not indicate orders for double portions at breakfast or a house supplement. The same document showed an order that R23 may receive calorie, protein, and/or nutrient supplements per the dietitian's recommendation. R23's meal ticket printed on 6/4/25 did not indicate he was…

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

Based on interview and record review the facility failed to follow dialysis recommendations for daily weights for 1 of 2 residents (R27) reviewed for dialysis in the sample of 20. The findings include: R27's face sheet shows he has diagnoses including: End Stage Renal Disease, Dependence on Renal Dialysis, and Dementia. A Health Status Note completed by V15 (Registered Nurse) on 5/21/25 at 9:14 PM, shows that R27 had gone out to dialysis and returned at 3:55 PM. The note also states, Per dialysis they would like pt (patient) on a 1200 CC fluid restriction and daily weights. R27's active Physician Order Summaries show the dialysis recommended daily weights was added into the active orders on 5/21/25. R27's Electronic Medical Record (EMR's) Weight Summary report and Medication Administration Record Summary (MAR) show he was weighed on 5/24/25 with no additional recorded weights after that date. On 6/3/25 at 11:48 AM, V9 (Licensed Practical Nurse/LPN) said R27 is weighed via a mechanical lift scale and does not refuse to be weighed. V9 said R27 goes to dialysis 3 times a week and she…

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.

3.On 06/02/25 at 1:32 PM, V10 CNA-Certified Nursing Assistant emptied R47's indwelling urinary catheter bag. V10 CNA did not wear a gown when emptying the urinary collection bag. R47's room door had a sign that showed, Enhanced Barrier Precautions. Staff must wear gloves and a gown when providing care for a resident with a urinary catheter. On 06/04/25 at 10:05 AM, V2 DON-Director of Nursing said, residents with indwelling urinary catheters are on EBP-Enhanced Barrier Precautions. There is a chance of being splashed by urine when emptying the urinary catheter bag, gloves and a gown should be worn. We also provide face shields to protect the staff's eyes. The facility's Enhanced Barrier Precautions dated 04/2024 shows, Implementation of Enhanced Barrier Precautions: Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. PPE-Personal Protective Equipment for enhanced barrier precautions is only necessary when performing high-contact care activities High-Contact…

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

Based on interview and record review the facility failed to have documentation that residents received or refused the pneumococcal vaccine for 2 of 5 residents (R11 and R28) reviewed for immunizations in the sample of 20. The findings include: R11 and R28's immunization records printed on 6/3/25 did not indicate they received or declined the pneumococcal vaccine On 06/03/25 at 11:28 AM, V2 (Director of Nursing) said the facility did not have documentations indicating R11 or R28 received or declined the pneumococcal vaccine. The immunization policy was requested on 6/3/25 and the facility could not provide the policy prior to exiting the facility on 6/4/25.

Based on interview and record review the facility failed to administer medications at the scheduled times for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 3. The findings include: R1's Face Sheet dated 5/5/25 showed R1 was diagnosed with congestive heart failure and lymphedema. A facility assessment done on 3/5/25 showed R1's mental status was intact. R1's orders showed an order for bumetanide (water pill) and potassium to be given twice a day. On 5/5/25 at 10:00 AM, R1 said his morning medications were late on 5/1/25 and 5/4/25 by nearly 3 hours. R1's Medication Admin Audit Report for 5/1/25 showed the morning doses of R1's bumetanide and potassium were scheduled for 7:30 AM. The document showed the medications were administered at 10:15 AM (2 hours and 45 minutes late). The medications were signed off by V6 (Licensed Practical Nurse). R1's Medication Admin Audit Report for 5/4/25 showed the morning doses of R1's bumetanide and potassium were scheduled for 7:30 AM. The bumetanide was signed off as administered at 9:35 AM (2 hours and 5 minutes late). R1's…

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

Based on interview and record review the facility failed to ensure an incident of verbal abuse was reported to the state agency. This applies to 2 of 3 residents (R1000, R1001) reviewed for abuse in the sample of 3. The findings include: On 6/11/25 at 9:25 AM, V2 (Director of Nursing) said on the morning of 6/9/25, R1001 was being assisted back to R1001's room when R1001 became verbally aggressive, shouting at staff using foul language and using racial slurs. V2 said as R1001 passed R1000's doorway, R1001 and R1000 exchanged words leading to R1001 calling R1000 a fat*ss and R1001 was being nasty towards R1000. V2 said the incident was not reported to the state agency and she felt the incident was more of a verbal altercation and not verbal abuse. On 6/11/25 at 1:15 PM, V1 (Administrator) said he was initially unaware of the altercation on 6/9/25 between R1000 and R1001 and believed the incident talked about with V2 at 9:25 AM was a previous incident. V1 also talked with R1000 about the incident and said that R1000 did believe the incident was verbally abusive and not just a verbal…

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 verbal abuse from another resident. This applies to 2 of 4 residents (R5 and R6) reviewed for abuse in the sample of 6. The findings include: R6's Face Sheet dated 3/31/25 shows R6 has diagnoses that include, but are not limited to: adjustment disorder with mixed anxiety and depressed mood and other specified depressive episodes. R5's Care Plan initiated 10/23/24 shows that R5 has a history of becoming verbally aggressive towards staff. On 3/31/25 at 1:35 PM, V9 (Certified Nursing Assistant- CNA) said towards the end of V9's shift on Saturday, 3/29/25, V9 was providing care to another resident when V9 entered the hallway and saw R5's call light on. Without going to R5's room, V9 asked R5 what R5 needed and R5 responded saying R5 needed water. V9 acknowledged R5's request and told R5 that V9 will get R5 water when V9 finished caring for the resident V9 was working with. When V9 finished and exited the other resident's room, V9 saw that R5's call light was no longer on and had believed the…

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

Based on interview and record review the facility failed to ensure an allegation of resident to resident verbal abuse was immediately reported to the administrator, and reported to the state agency. This applies to 2 of 4 residents (R5 and R6) reviewed for abuse in the sample of 6. The findings include: On 3/31/25 at 1:35 PM, V9 (Certified Nursing Assistant- CNA) said on Saturday, 3/29/25 during V9's shift, R5 got verbally and physically aggressive towards V9 which turned into R5 and R6 engaging in a verbal altercation. This verbal altercation resulted in R5 calling R6 a f*ucking b*tch and a fat b*tch. V9 said after leaving the facility after V9's shift ended, V9 sent V2 (Director of Nursing) a text message informing V2 about the altercation involving V9 and R5. V9 did not notify V2 of the details about R5 and R6. On 3/31/25 at 1:52 PM, V10 (RN) said after talking with and assessing R5 and R6 and providing R6 with anxiety medication, V10 called V1 (Administrator) and V2 and informed them of the incident. V10 did not provide V1 and V2 with all of the specific words that were used…

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 supervise a resident who wanders and has physical aggressive behaviors towards others. This applies to 2 of 15 residents (R12, R13) reviewed for safety in the sample of 15. The findings include: 1. R13's face sheet shows he is a [AGE] year-old male with diagnosis including bipolar, paranoid schizophrenia, schizoaffective disorder, unspecified mood (affective) disorder, anxiety, disorders of and psychosocial development. The facility's Final Abuse Investigation dated 3/18/25 documents on 3/16/25, (R12) reported that (R13) allegedly hit her on the head (R12) reported that she was backing out of the common area with her wheelchair and mistakenly ran into (R13) and (R13) hit her. The Final report shows (R12) stated staff members were in the dining room monitoring them all along and this happened before the staff could stop (R13). (R12) stated the staff separated (R13) from her .residents who witnessed this allegation stated, (R12) ran into R13…

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

Based on interview and record review the facility failed to ensure a resident received their medications. This applies to 1 of 1 resident (R2) reviewed for medications in the sample of 15. The findings include: R2's Face sheet shows R2 has diagnoses that include but are not limited to; acute combined systolic (congestive) and diastolic (congestive) heart failure, acute and chronic respiratory failure, lymphedema, hypertension, anemia, and hypokalemia. On 3/17/25 at 9:25 AM, R2 said V10 (Licensed Practical Nurse/LPN) doesn't provide his diuretic and potassium pills at the correct time, and he frequently gets delayed medications. R2 also stated that his legs were no longer weeping fluid, the fluid in his legs has decreased, and he no longer needs to wear tight bandages on his legs. On 3/18/25 at 9:35 AM, V10 (LPN) said for roughly a month or longer, V10 stopped caring for R2 when V10 worked, because R2 would get verbally aggressive towards V10 and use racial slurs against V10. V10 is no longer comfortable providing care for R2 and does not provide V10 medications. V10 said the nurse…

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

Based on interview and record review the facility failed to ensure residents were treated with respect and dignity for 7 of 9 residents (R1, R3, R4, R6, R7, R8, R9) reviewed for resident rights in the sample of 9. The findings include: On 3/4/25 at 10:13 AM, R1 stated she told staff that she did not want a specific agency CNA (Certified Nurse Aide) caring for her anymore. R1 said the CNA had a bad attitude, spoke in a loud tone, and did not change her wet briefs quick enough. R1 said she told V3 (CNA Scheduler) about the request. R1 said the same aide was in her room about two weeks later and helping her roommate. R1 said the overnight aides are lazy and ignore her call light. On 3/4/25 at 10:50 AM, R3 stated she only trusts facility staff to care for her. R3 said the agency CNAs tell her to mind her own business if she complains. R3 said they speak rudely, don't know how to listen, and call her bossy. R3 said she has seen agency CNAs get reported and then they are still allowed to come back to the facility. On 3/4/25 at 12:48 PM, R4 said a CNA yelled at him when he asked where 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.

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 allowed to stay in there room. This failure applies to 1 of 7 residents (R1) reviewed for room transfers in a sample of 7. The findings include: R1's Electronic Medical Record showed R1 is a cognitively intact [AGE] year old female who was admitted to the facility into a room on the 300 hallway. On 12/30/24 at 08:45 AM, R1 stated on 12/24/24 V1 Administrator came to R1's room, and told R1 they had to move to a different room. R1 stated V1 told her it was because they needed the room for a COVID positive resident. R1 stated she had been in that room since she was admitted to the facility in mid September. R1 stated she told V1 she did not want to move to a different room which ended up in an argument. R1 stated she was asked again on 12/25/24 about moving rooms. R1 stated she told V1 she did not want to move. R1 stated on 12/27/24 she was out on pass. R1 stated she left the facility around 10:00 AM with V5 (R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was free from verbal abuse which applies to 1 of 7 residents (R1) reviewed for verbal abuse in a sample of 7. The findings include: R1's Facility assessment dated [DATE] showed R1 is a cognitively intact [AGE] year old female resident admitted to the facility on [DATE]. On 12/30/24 at 9:00 AM, R1 stated on 12/24/24 V1 had come to her room and told her she needed to move rooms. R1 stated she did not want to move. R1 stated sometime after 4:00 PM, V1 came back and started arguing with her about changing rooms. R1 stated at one point V1 closed the door and started yelling at her about moving my belongings to another room. R1 stated it made her worried when he shut the door, came closer to her, and started yelling at her she had to move rooms. R1 stated V8 Registered Nurse opened the door, and V1 left. R1 stated she was mad after V1 left the room. On 12/30/24 at 10:30 AM, V1 stated he did go into R1's room to try to get her to move so they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an allegation of abuse to the facility designee and failed to report an allegation of abuse to the State Agency in a timely manner which applies to 1 of 7 residents (R1) reviewed abuse notification in a sample of 7. The findings include: R1's Facility assessment dated [DATE] showed R1 is a cognitively intact [AGE] year old female resident admitted to the facility on [DATE]. On 12/30/24 at 9:00 AM, R1 stated on 12/24/24 V1 had come into her room and started yelling at her about moving rooms. V1 came into the room and closed the door. R1 stated V1 came over, went to pick up my pop off the floor. R1 stated she went to pull the pop away from V1. R1 stated V1's arm and the pop struck her in the face. R1 stated she yelled Ow, you hit me! then V1 stated No, you pulled me!. On 12/30/24 at 10:30 AM, V1 stated he did go into R1's room to try to get her to move so they could use the room for a COVID-19 positive resident. R1 stated she did not want to move.…

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 initiate an investigation after an allegation of abuse and failed to remove an alleged perpetrator from the building following an allegation of abuse for 1 of 7 residents (R1) reviewed for abuse investigations in a sample of 7. The findings include: 1. The facility final Incidents Report showed R1's documentation was sent to (State Agency) on 12/27/24. This report showed the police were called to the facility and found no evidence to substantiate the allegation of physical abuse. The report showed no entries of any verbal allegations of abuse. On 12/30/24 at 10:30 AM, V1 (Administrator) stated the police were in the facility after R1 said V1 struck her. V1 stated the police talked to myself, and they said R1 had no signs of physical abuse. The police who came said it was unsubstantiated. V1 stated he sent all the information about the incident to (State Agency) On 12/30/24 at 3:25 PM, V5 (R1's driver) stated he was in the room when R1 and V1 were yelling at each other. V5 stated his back was to R1 and V1 when R1 said she…

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 five residents with norovirus-like symptoms (R7, R8, R11, R13, R15) were isolated to prevent cross contamination during the facility norovirus outbreak. This has the potential to affect all 76 residents residing at the facility. The findings include: 1. On 12/17/24 at 10:00 AM, R7 said she had vomiting and diarrhea over the weekend. R7 said she stayed in her room with her roommates (R8 and R13). R8 said she also had diarrhea last Sunday and another episode of diarrhea last night. R13 said today she does not feel well. R13 said she felt nauseous. Last Sunday night (12/15/24) she vomited and then started to also have diarrhea last night. The facility's line list for residents with norovirus (a highly contagious viral illness that causes vomiting and diarrhea) shows that both R7 and R8 had norovirus-like symptoms of diarrhea that started on 12/13/24. On 12/16/24 the line list shows the other roommate, R13, had vomiting on 12/16/24. The line list did not include R13's diarrhea last night (per R13). 2. On 12/17/24 at 9:12…

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 facility-initiated discharge documentation was included in the resident's medical record for 1 of 5 residents (R1) reviewed for resident discharge documentation in a sample of 5. The findings include: R1's Facility assessment dated [DATE] showed R1 is a sixty-six-year-old, cognitively intact resident. This assessment showed R1 was admitted to the facility on [DATE] with diagnoses which included seizures, foot drop, post-traumatic osteoarthritis, anxiety, post-traumatic stress disorder, and hypertension. R1's Physician Orders dated 12/11/24 showed no physician order for R1's discharge/transfer out of the facility. On 12/11/24 at 2:30 PM, R1 stated the facility did not talk to me about discharging until the day I was sent out. They told me they found me placement in a facility and got sent out later that night. R1's Progress Notes, Social Services Notes, Primary Care Notes, and Psychiatric Notes showed no summary or discussions of discharge plans…

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 appropriate supervision was in place for a resident on pass to the community for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 16. The findings include: On 10/10/24 at 11:11 AM, R1 said R2 drove her to a local store to go shopping for gym shoes. R1 said on the way back from the store, R2 pulled into a local forest preserve and exposed his penis to her and propositioned her. R1 said R2 gave her a ride a couple times. R1 said the facility knew that she was going shopping with R2. On 10/10/24 at 12:36 PM, R2 said he had a car at the facility and he went out on pass a few times a week. R2 said he had driven R1 around a couple of times. R2 said he took R1 to the store and they did stop at the forest preserve, but he didn't expose himself. R2 said he stopped there to use the bathroom. R2 said the facility knew he took R1 shopping. R2 said R1 started blowing up his phone and hounding him for rides and he didn't want to. R2…

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 an ankle brace and hand splint for residents with limited range of motion. This applies to 2 of 3 residents (R1, R6) reviewed for splints/devices in the sample of 7. The findings include: 1. R1's face sheet shows she is a [AGE] year-old female with diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, fibromyalgia, history of falls, muscle weakness, other specified disorders of muscle, torus fracture of lower end of right fibula. On 9/9/24 at 9:42 AM, R1 was observed in her room sitting in her electric wheelchair. Her right foot was positioned outward towards the right on the wheelchair's foot board. R1 said she is supposed to have an ankle brace months ago. R1 said, V2 (Assistant Administrator) said he ordered the brace, and it was coming for several weeks. First, he said it was sent to the wrong facility and the previous maintenance staff was going to pick…

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

Based on interview and record review the facility failed to follow their Abuse Policy by not ensuring that staff reported an allegation of sexual abuse to the Administrator and by not investigating an allegation of sexual abuse. This applies to 4 of 14 residents (R4, R11, R18 and R22) reviewed for abuse in the sample of 22. The findings include: The facility policy entitled Abuse, Neglect and Exploitation dated 9/2023 states, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of resident property. This policy also defines sexual abuse as non-consensual sexual contact of any type with a resident and lists the 8 components of abuse prevention as Screening, Employee Training, Prevention of Abuse, Neglect and Exploitation, Identification of Abuse Neglect and Exploitation, Investigation of Alleged Abuse, Neglect and Exploitation, Protection of Residents, Reporting/Response and Coordination…

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 that staff report an allegation of resident to resident sexual abuse to the Administrator or designee. This applies to 2 of 14 residents (R22 and R18) reviewed for abuse in the sample of 22. The findings include: The facility reported incident dated 7/10/24 states, On 7/10/24 at approximately 5:15 PM it was reported to the (V20- Director for Clinical Excellence/Corporate Nurse) while conducting interviews of residents on if they experienced any inappropriate behaviors towards them by other residents, (R22) stated no. As (V20) walked out of the room, the (R22) then stated actually 'yes, (R18) touched my breast on Thursday 7/4/24.' Upon initial investigation it was discovered that this allegation was actually on Friday 7/5/24 as staff that she said was working in the facility that day, was in fact not. (R18) is currently on 1:1 supervision. Family, MD and ombudsman of both residents were notified. Investigation initiated. Final report due in 5 days. On 7/11/24 at 10:00 AM R22 stated, It was during the day in the dining…

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 investigate an allegation of resident to resident sexual abuse. This applies to 1 of 14 residents (R11 and R4) reviewed for abuse in the sample of 22. The findings include: On 7/5/24 at 11:30 AM, V8 (Registered Nurse) stated, I was doing my 8:00 PM med pass and (R11) was shaking and crying and very upset. I went in and asked her what was wrong, and she told me her and (R4) had eaten dinner together in the dining room. (R4) followed her back to her room and came in her room and pulled his penis out and put it on her leg and told her to touch it. She excused herself and went into the bathroom and through the to the other room and told (R14) that she 'needed the CNA (Certified Nursing Assistant) now' and (R14) got the CNA to remove (R4) from the room. I don't know who the CNA was, and I don't think (R11) ever told the CNA what had happened. I notified (R2- Director of Nursing/DON) but I didn't notify (V1- Assistant Administrator) because he doesn't answer his phone after dark. I charted all of it and it should be there. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's code status was assessed and documented for 1 of 18 residents (R75) reviewed for advanced directives in the sample of 18. The findings include: As of 5/15/24 at 1:00 PM, R75s Electronic Medical Record (EMR) shows nothing under Code Status in the heading section. R75's admission Record dated 5/14/24 shows R75 was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, Multiple Sclerosis, muscle weakness, lack of coordination, abnormal posture, cognitive communication deficit, diabetes, hypertension, chronic pain syndrome, hypothyroidism, and need for assistance with personal care. R75's Order Summary Report dated 5/14/24 shows no order for a code status. R75's EMR has no Advanced Directives forms. R75's current care plan provided by the facility does not address advanced directives. On 5/15/24 at 10:17 AM, V23, Licensed Practical Nurse, said she will look at the heading on a resident's EMR for their code…

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 male resident did not expose his private areas to female residents while outside on the smoking patio. This applies to 2 of 18 residents (R8 & R279) reviewed for abuse in the sample of 18. The findings include: R279's EMR (Electronic Medical Record) shows that R279 was admitted to the facility on [DATE] with diagnoses including Morbid Obesity, Nicotine Dependence, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Peripheral Vascular Disease and Anxiety Disorder. R279 was discharged to another facility on 4/5/24. On 5/14/24 at 1:05 PM R8 stated, (R279) was very sexually perverted. I saw his private organ. He let it hang out outside and then he would come in leave it is hanging out when he was going down the hall. Then he molested a helpless little old lady. He did it twice. The first time he got reprimanded for it and then he did it again. Both times he was touching her breast. About one month in between. That…

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

Based on observation, interview, and record review the facility failed to implement Physician Ordered treatments for 2 of 18 residents (R50, R179) reviewed for physician orders in the sample of 18. The findings include: 1.On 05/13/24 at 9:43 AM, R50 was lying in bed. There was a sign on wall that shows, COMPRESSION STOCKING ON IN AM OFF AT BEDTIME. Abdominal binder on when up. R50 was not wearing his compression stockings. On 05/14/24 at 9:10AM, R50 was not wearing compression socks. On 05/13/24 at 9:43AM, R50 stated, I wear the compression stockings to help with circulation. On 05/14/24 at 9:12AM, V10 LPN-Licensed Practical Nurse said, the nurses or the CNA-Certified Nursing Assistant will put the socks on. When the physician order is AM, it means between 8:00AM, to 9:00AM. R50's Physician Order dated 04/16/2023 at 2:18PM, shows, compression stockings on in AM off in PM for hypotension. The facility's Applying Anti-emboli Stockings dated 10/2010 shows, the purpose of this procedure is to improve venous return to the heart, to improve arterial circulation to the feet, to minimize…

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 treatment orders were administered as ordered for 1 of 18 residents (R28) reviewed for quality of care in the sample of 18. The findings include: On 5/13/24 at 9:30 AM, R28 had a dressing to the top of his head initialed and dated 5/10. The dressing was soiled with drainage saturating about one half of the dressing. On 5/13/24 at 11:55 AM, V9, Registered Nurse, said the wound care nurse does the wound treatments, as ordered, but if a resident's dressing comes off or becomes soiled, the nurse caring for the resident will need to change/replace the dressing. V9 said the nurse initials and dates the dressing after completing the treatment. R28's Order Summary Report dated 5/14/24 shows orders dated 3/28/24 as follows: Scalp lesion: cleanse with normal saline solution, cover with calcium alginate, then island dressing every other day and every six hours as needed for soiled/missing dressing. The facility's Wound Treatment Management Policy (revised 6/23) shows wound treatments will be provided in accordance…

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 wore their prescribed orthotic devices (splints) and failed to ensure residents were provided with a restorative program for 3 of 3 residents reviewed for range of motion in the sample of 18. The findings include: 1. On 5/13/24 at 10:08 AM, R25 was in his wheelchair in the hall. R25 had no brace on his right hand. On 5/14/24 at 8:36 AM R25 again had no brace to his right hand. On 5/14/24 at 9:26 AM, V13, Director of Rehab, said R25 has a hand splint for his right hand to prevent contractures. V13 said R25 is supposed to wear the splint during the day, and it can be off at night. V13 said if a resident does not wear their brace, they risk loss of mobility, pain, swelling, and contractures. V13 said R25 should have a care plan to include range of motion (ROM). V13 said if therapy recommends restorative therapy for residents, they discuss it in the care plan meeting, as there is no restorative nurse in the facility. V13 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 insidious weight loss received a dietary intervention of ice cream with lunch for 1 of 6 residents (R71) reviewed for nutrition in the sample of 18. The findings include: R71's weight summary showed R71 weighed 166 pounds on 3/5/2024 and 157.5 pounds on 5/7/2024 (8.5 pound weight loss). R71's Order Summary Report showed an order that R71 may receive calorie, protein and/or nutrient supplements per dietician recommendation. R71 had an active order per dietician's recommendation for ice cream with lunch and dinner. R71's Nutrition/Dietary Note dated 11/9/2023 showed R71 was to get ice cream with lunch and dinner for additional calories and protein. On 05/13/24 at 12:53 PM, R71 was in his room. V5 (Certified Nursing Assistant) was assisting R71 to eat. R71 did not have ice cream on his meal tray. V5 confirmed R71 did not receive ice cream with his lunch on 5/13/24. On 5/14/24 at 12:48 PM, V3 (Dietician) said R71 had lost weight (insidious) but had not triggered for a significant weight…

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 the oxygen humidifier bottle was changed every 72 hours for 1 of 5 residents (R30) reviewed for respiratory care in the sample of 18. The findings include: On 5/13/24 at 10:11 AM, R30 was in his wheelchair in his room. R30 had his oxygen tubing in his nares and the oxygen humidifier bottle was dated 2/8/24. On 5/14/24 at 3:08 PM, V10, Licensed Practical Nurse, said residents' oxygen tubing and humidifier bottle is supposed to be changed every week, usually on Sundays, by the nurse. R30's Order Summary Report dated 5/14/24 shows an active order for R30 to receive oxygen at 2-3 liters/minute per nasal cannula as needed for shortness of breath. The facility's Oxygen Administration Policy dated 1/2024 shows the oxygen humidifier bottle is to be changed every 72 hours.

Based on observation, interview, and record review, the facility failed to ensure a resident on Transmission Based Precautions had signage outside his room to indicate the isolation precautions for 1 of 18 residents (R28) reviewed for infection prevention in the sample of 18. The findings include: On 5/13/24 at 1:37 PM, R28's room had no signage displayed to indicate he was on isolation precautions of any kind. On 5/14/24 at 8:15 AM, R28's room had no signage displayed to indicate he was on isolation precautions of any kind. On 5/14/24 at 9:20 AM, V12, Certified Nursing Assistant, said she knows when a resident is on isolation because residents on isolation have a sign on their door showing they are on isolation. V12 said the sign tells what Personal Protective Equipment (PPE) should be worn in the room. R28's admission Record dated 5/14/24 shows R28 has an unspecified open wound of his scalp, an unspecified open wound of his right lower leg, and need for assistance with personal care. R28's Order Summary Report dated 5/14/24 shows R28 has an active order for Enhanced Barrier…

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

Based on interview and record review the facility failed to follow their Abuse Policy by not ensuring that staff report an allegation of sexual abuse to the Administrator and by not investigating an allegation of sexual abuse. This applies to 2 of 18 residents (R27 & R279) reviewed for abuse in a sample of 18. The finding include: On 5/14/24 an allegation of sexual abuse was given to a surveyor from an anonymous complainant. The allegation stated, On April 3 there was an incident verbally reported (but not charted) that (R279) sexually assaulted a mute, cognitively impaired resident, (R27). (V1- Administrator) and several managers reviewed the video footage (behind closed doors), and it was determined that a sexual assault had occurred. On 5/14/24 at 1:25PM, V2 (Director of Nursing) stated, (R279) is no longer here. At times he would go out to smoke, and he would expose himself. He was called out on it a couple of times and he said he wouldn't do it again, but it didn't stop. He didn't ever verbalize anything sexual towards staff or other residents. There was an issue with one…

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

Based on interview and record review the facility failed to report an allegation of sexual abuse to the administrator and to the State Agency. This applies to 2 of 18 residents (R27 & R279) reviewed for abuse in the sample of 18. The findings include: On 5/14/24 an allegation of sexual abuse was given to a surveyor from an anonymous complainant. The allegation stated, On April 3 there was an incident verbally reported (but not charted) that (R279) sexually assaulted a mute, cognitively impaired resident, (R27). (V1- Administrator) and several managers reviewed the video footage (behind closed doors) and it was determined that a sexual assault had occurred. On 5/14/24 at 1:25PM, V2 (Director of Nursing) stated, (R279) is no longer here. At times he would go out to smoke, and he would expose himself. He was called out on it a couple of times and he said he wouldn't do it again, but it didn't stop. He didn't ever verbalize anything sexual towards staff or other residents. There was an issue with one resident (R27) and they thought that he had touched her. (R27) was in the hallway 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 investigate an allegation of sexual abuse. This applies to 2 of 18 residents (R27 & R279) reviewed for abuse in the sample of 18. The findings include: On 5/14/24 an allegation of sexual abuse was given to a surveyor from an anonymous complainant. The allegation stated, On April 3 there was an incident verbally reported (but not charted) that (R279) sexually assaulted a mute, cognitively impaired resident, (R27). (V1- Administrator) and several managers reviewed the video footage (behind closed doors) and it was determined that a sexual assault had occurred. R279's EMR (Electronic Medical Record) shows that R279 was admitted to the facility on [DATE] with diagnoses including Morbid Obesity, Nicotine Dependence, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Peripheral Vascular Disease and Anxiety Disorder. R279 was discharged to another facility on 4/5/24. R27's EMR shows that she was admitted to the facility 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 observation, interview, and record review the facility failed to ensure the alarms on 2 of 7 exit doors were functional. This applies to 3 of 3 residents (R5, R8, R9) reviewed for elopement risk in the sample of 9. The findings include: 1. On 2/27/24 at 9:45 AM, this surveyor was able to open the emergency exit door at the end of the 400 hall and exit the building without the alarm sounding. On 2/27/24 at 1:22 PM, this surveyor was able to open the emergency exit door in the 300 conference room located at the end of the 300 hall and exit the building without the alarm sounding. Facility provided list of residents at risk for elopement shows that R5, R8, and R9 are at risk for elopement. R5's Elopement Risk Evaluation dated 11/15/23 shows R5 has purposeful exit seeking behavior and is at risk for elopement. R5's Behavior Note dated 11/10/23 at 4:13 PM states, resident eloped out the 300 emergency exit door, second registered nurse (RN) was able to redirect resident back into building, resident is very…

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 honor a resident's right to have a visitor by informing a visitor that visiting hours ended at 8:00 PM. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 3. The findings include: R1's face sheet showed R1 was [AGE] years old and had the following diagnoses: osteomyelitis (bone infection), diabetes, high blood pressure, and history of cancer. On 1/31/24 at 12:56 PM, V6 (Social Worker) described R1 as alert and oriented and aware of what was going on. On 1/31/24 at 8:15 AM, R1 said on 1/28/24 V4 (R1's sister) was visiting him and staff wanted her to leave by 8:00 PM because that was when visiting hours ended. R1 said V4 left because visiting hours were ending, and he wanted V4 to stay longer. R1 said he was visiting with V4 in his room and he did not have a roommate. On 1/31/24 at 12:33 PM, V4 said on 1/28/24 V8 (Register Nurse) informed her visiting hours were from 8:00 AM - 8:00 PM and she had to leave by 8:00 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 interview and record review the facility failed to ensure a resident was free from verbal and mental abuse for 1 of 5 residents (R1) reviewed for abuse in the sample of 5. The findings include: R1's Minimum Data Set assessment dated [DATE] shows R1's cognition is intact. On 11/28/23 at 9:33 AM, R1 said the other day (11/20/23) he went to the nurses station to get his medication from V3 (Registered Nurse/RN). R1 said he then went back a short while later to ask if he had received his as needed medication. R1 said he did not remember the name of it but it started with a 'T. R1 said V3 then said, I can't keep getting up and down, up and down. R1 said V3 stated, How am I supposed to give you a medication if you don't even know the name of it. R1 said he has Alzheimer's Disease and has trouble remembering things. R1 said at time he said to her, Why are you bching at me? R1 said at one point, V3 got very upset and started yelling at him and told R1 he could not call her a bch. R1 said V3 then went 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.

Based on interview and record review the facility staff failed to immediately report an allegation of abuse to the administrator and the State Survey Agency for 1 of 5 residents (R1) reviewed for abuse in the sample of 5. The findings include: On 11/28/23 at 9:33 AM, R1 said the other day (11/20/23) he went to the nurses station to get his medication from V3 (Registered Nurse/RN). R1 said he then went back a short while later to ask if he had received his as needed medication. R1 said he did not remember the name of it but it started with a 'T. R1 said V3 then said, I can't keep getting up and down, up and down. R1 said V3 stated, How am I supposed to give you a medication if you don't even know the name of it. R1 said he has Alzheimer's Disease and has trouble remembering things. R1 said at time he said to her, Why are you bching at me? R1 said at one point, V3 got very upset and started yelling at him and told R1 he could not call her a bch. R1 said V3 then went to the medication cart and started slamming things around. R1 said he then asked her if she found the medication and…

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

Based on interview and record review the facility staff failed to investigate an allegation of abuse and protect the resident from further abuse while the investigation is in progress for 1 of 5 residents (R1) reviewed for abuse in the sample of 5. The findings include: On 11/28/23 at 9:33 AM, R1 said the other day (11/20/23) he went to the nurses station to get his medication from V3 (Registered Nurse/RN). R1 said he then went back a short while later to ask if he had received his as needed medication. R1 said he did not remember the name of it but it started with a 'T. R1 said V3 then said, I can't keep getting up and down, up and down. R1 said V3 stated, How am I supposed to give you a medication if you don't even know the name of it. R1 said he has Alzheimer's Disease and has trouble remembering things. R1 said at time he said to her, Why are you bching at me? R1 said at one point, V3 got very upset and started yelling at him and told R1 he could not call her a bch. R1 said V3 then went to the medication cart and started slamming things around. R1 said he then asked her if…

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 residents' shower was maintained comfortable and homelike for 4 of 11 residents (R1, R2, R5, and R8) reviewed for safe, clean, comfortable homelike environment in the sample of eleven. The finding include: On 09/11/23 at 8:54AM, R2 said, there is mold in the 300-hall shower. On 09/11/23 at 12:11PM, the 300-hall shower had a mottling of black, white, light brown, pink color in the corners where the shower floor and shower walls meet. On 09/11/23 at 12:11PM, V3 Housekeeping said, I have sprayed bleach on the area and scrubbed it, the color will not come off. On 09/11/23 at 12:28PM, V4 Maintenance said, I have not received any complaints about dark or black caulk around the shower. I get work orders on items that I need to attend to. Any staff member can fill out a work order. Residents usually have the receptionist fill out the work order. We do have lime build up. The water softener is not working. On 09/11/23 V6 CNA-Certified Nursing Assistant provided a list of residents that used the 300-hall shower. The list shows…

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 with contractures or who were at risks of developing contractures received range of motion for 5 of 6 residents (R27, R22, R56, R23 and R59) reviewed for range of motion in the sample of 19. The findings include: 1. R27's admission Record, printed by the facility on 4/12/23, showed he had diagnoses including cerebral palsy, anxiety disorder, and adjustment disorder with depressed mood. R27's facility assessment dated [DATE] showed he was dependent on staff for bed mobility, transfers, toileting, dressing, and personal hygiene. The assessment showed R27 had a limitation in range of motion to his bilateral upper and lower extremities. R27's plan of care. with a target date of 6/27/23, showed he requires passive range of motion (PROM) exercises to his extremities related to limited mobility and contractures to his upper and lower extremities. The plan of care showed R27 would participate in PROM exercise to bilateral lower…

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 call lights were being answered in a timely manner for 2 of 2 residents (R7 & R67) reviewed for dignity in the sample of 19. The findings include: 1. On 4/11/23 at 1:56 PM, R7 stated she must wait 45 minutes for her call light to be answered and receive assistance. R7 stated she must wait so long to be taken to the bathroom that she will wet herself. R7 stated it makes her feel awful and she cries about it. R7 stated this usually happens in the morning. R7 stated she will put her call light on in the morning and sometimes falls asleep while waiting for it to be answered. R7 stated staff will turn off the call light and leave and never ask her what she needed. R7's roommate (R46 - resident council president) was present and stated she has seen staff come in, turn off the call light and just leave without asking R7 what she needed. R7 stated it gets so bad that she will wet herself and she doesn't know how to fix the problem. The admission Record…

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 received a bath/shower weekly and complete cleansing of a resident's peri-area was done after an incontinence episode for 2 of 2 residents (R25 & R23) reviewed for activities of daily living in the sample of 19. The findings include: 1. On 4/11/23 at 10:28 AM, V6 CNA (Certified Nursing Assistant) Supervisor and V10 CNA were at R25's bedside. R25 was disheveled and had greasy hair. R25 was upset and crying. R25 stated she was in isolation for a couple of weeks because she had a UTI (urinary tract infection) and she didn't get a shower. V6 and V10 stated when a resident is on isolation the get bed baths. R25 stated she did not get a bed bath for two weeks. V6 stated residents were to get showers or bed baths twice per week. The shower/bathing schedule depends on the room the resident is in. V6 and V10 stated they did not know why R25 did not receive a bed bath. V6 stated skin sheets were done with showers and bed baths.…

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 supervise a resident with seizure-like activity when the resident was outside smoking. The facility also failed to transfer a resident to a shower chair in a safe manner. This applies to 2 of 9 residents (R46, R25) reviewed for safety and supervision in the sample of 19. The findings include: R46's admission Record, printed by the facility on 4/12/23, showed she had diagnoses including bipolar disorder, major depressive disorder, generalized anxiety disorder, paranoid schizophrenia, obsessive compulsive disorder, PTSD, and dissociative and conversion disorder. R46's facility assessment dated [DATE] showed R46 was cognitively intact (BIMS score of 15). On 4/11/23 at 12:04 PM, R8 came in from the outside smoking area and informed this surveyor that R46 had just had a seizure while they were outside smoking. R8 said one of the other residents (a male was all she would say) held R46's head while she was having the seizure, so she did not hit…

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 oxygen was administered as prescribed. This applies to 1 of 2 residents (R57) reviewed for oxygen use in the sample of 19. The findings include: R57's admission Record, printed 4/13/23 shows his diagnoses to include acute respiratory failure, personal history of COVID-19, heart failure, muscle weakness and cognitive communication deficit. R57's 12/20/22 MDS (Minimum Data Set) shows he needs extensive assistance with all his ADL's (Activities of daily living). The same MDS shows his is moderately cognitively impaired. On 4/11/23 at 9:44 AM, R57 was sitting in wheel chair and had his O2 (oxygen) on his nose using a nasal cannula. R57's O2 canister's dial was indicating it was empty (needle at the bottom of the dial, in the red zone). On 4/11/23 at 9:50 AM, V8, (Activity Director), asks R57 if he wants to attend an activity and R57 started to self propel himself out room slowly with his portable O2 canister's dial indicating it was empty. On 4/11/23 at 12:21 PM, V9 CNA (Certified Nursing Assistant) assists…

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 incontinent care in a manner to prevent infection and failed to clean urine from the floor and from a non-skid pad to prevent cross contamination for 3 of 3 residents (R27, R23 and R22) reviewed for infection control in the sample of 19. The findings include: 1. R27's admission Record, printed by the facility on 4/12/23, showed he had diagnoses including cerebral palsy, anxiety disorder, and adjustment disorder with depressed mood. R27's facility assessment dated [DATE] showed he was dependent on staff for bed mobility, transfers, toileting, dressing and personal hygiene. The assessment showed R27 had a limitation in range of motion to his bilateral upper and lower extremities. R27's ADL (activities of daily living) plan of care, with a target date of 6/27/23, showed he is totally dependent on staff for toileting and personal hygiene. R27's incontinence plan of care, with a target date of 6/27/23, showed he is incontinent of…

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