Allure Of Zion

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure glove changes were performed during incontinence care for a resident with a history of ESBL (Extended-spectrum beta-lactamase) in the urine. This applies to 1 of 3 residents (R1) reviewed for incontinence care in the sample of 3.The findings include:R1's electronic face sheet printed on 12/4/25 showed R1 has diagnoses including but not limited to Parkinson's Disease, congestive heart failure, major depressive disorder, hallucinations, and anxiety disorder.R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment, is incontinent of bladder, and requires staff assistance for personal hygiene.R1's physician's orders dated 1/8/25 showed, Enhanced Barrier Precautions due to history of ESBL in urine .R1's care plan dated 7/31/25 showed, The resident requires Enhanced Barrier Precautions related to history of ESBL (Extended-Spectrum Beta-Lactamases) in the urine .wear personal protective equipment properly .On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medications as ordered by the physician for one of six residents (R1) reviewed for medications in the sample of six. The findings include: R1's Discharge Instructions from the local hospital dated June 13, 2025, shows R1 was admitted to the local hospital on June 4, 2025, with diagnoses including wet gangrene, osteomyelitis, and dementia. Amoxicillin-clavulanate (Augmentin 500 mg(milligram)-125 mg oral tablet/antibiotic) one tablet every eight hours with next dose due on June 13, 2025, at 5:00 PM was ordered by the discharging physician. R1's Physician Orders shows an order was entered for Augmentin one tablet three times per day for toe amputation with a start date of June 13, 2025. R1's Physician Orders show that R1 was admitted to the facility on [DATE]. R1's Medication Administration Record shows Augmentin was not administered until June 15, 2025, at 9:00 AM. On June 26, 2025, at 11:26 AM, via telephone interview with V2 Director of…

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

Based on interview and record review the facility failed to ensure residents were free of misappropriation of money for 4 of 4 residents (R1-R4) reviewed for misappropriation of property in the sample of 4. The findings include: 1. On 6/4/25 at 9:30 AM, R1 said that one night around midnight she was sleeping in bed when she awoke to a tall African American female going through her top nightstand drawer. R1 said that she said Hi to her and she immediately left the room. R1 said that that morning she checked her nightstand drawer and noticed her money missing. R1 said that she notified the staff, and they took care of it and she has not seen that staff member since. R1 said that she gets $60 a month and saves it in her top drawer of her nightstand. On 6/4/25 at 10:07 AM, V4 (Social Service Director) said that on 5/23/25, R1 was brought to her by a nurse and R1 said that she was missing around $200. V4 said that R1 told her that she saw a tall African American female in her room going through her belongings and the next morning is when she noticed the money was missing. On 6/4/25 at…

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 implement their Abuse Policy regarding reporting and investigating an alleged misappropriation of money for 1 of 4 residents (R4) reviewed for misappropriation of property in the sample of 4. The findings include: A Quality Improvement Form dated 4/1/25 shows that R4's daughter reported to V9 (Previous Social Service Director) that she left two envelopes containing $23 for her to pay to get her hair done. The envelopes were in the room on 3/19/25 and noticed both missing on 3/22/25. The form shows that the administrator was notified. A Quality Improvement Form dated 4/4/25 shows that R4's daughter reported that the resident was missing 4 envelopes of money totaling $86 that were in a zipper pocket of her purse that was located in her rollator walker. The form shows that the administrator was notified. An untitled document dated 4/7/25 to Illinois Department of Public Health (IDPH) shows that R4 reported that she has had money missing, an investigation has been initiated and a five-day final is to follow. The undated Final…

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 an alleged misappropriation of resident money was reported immediately to the State Survey Agency for 1 of 4 residents (R4) reviewed for misappropriation of property in the sample of 4. The findings include: A Quality Improvement Form dated 4/1/25 shows that R4's daughter reported to V9 (Previous Social Service Director) that she left two envelopes containing $23 for her to pay to get her hair done. The envelopes were in the room on 3/19/25 and noticed both missing on 3/22/25. The form shows that the administrator was notified. A Quality Improvement Form dated 4/4/25 shows that R4's daughter reported that the resident was missing 4 envelopes of money totaling $86 that were in a zipper pocket of her purse that was located in her rollator walker. The form shows that the administrator was notified. An untitled document dated 4/7/25 to Illinois Department of Public Health (IDPH) shows that R4 reported that she has had money missing, an investigation has been initiated and a five-day final is to follow. The undated…

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 of an alleged misappropriation of money 1 of 4 residents (R4) reviewed for misappropriation of property in the sample of 4. The findings include: A Quality Improvement Form dated 4/1/25 shows that R4's daughter reported to V9 (Previous Social Service Director) that she left two envelopes containing $23 for her to pay to get her hair done. The envelopes were in the room on 3/19/25 and noticed both missing on 3/22/25. The form shows that the administrator was notified. A Quality Improvement Form dated 4/4/25 shows that R4's daughter reported that the resident was missing 4 envelopes of money totaling $86 that were in a zipper pocket of her purse that was located in her rollator walker. The form shows that the administrator was notified. An untitled document dated 4/7/25 to Illinois Department of Public Health (IDPH) shows that R4 reported that she has had money missing, an investigation has been initiated and a five-day final is to follow. The undated Final Investigation related to allegation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure low air loss mattresses were provided for 2 of 3 residents (R2 and R3) with Stage 4 sacral pressure ulcers reviewed for pressure ulcers in the sample of 3. The findings include: R2's admission Record dated 5/5/25 shows R2 was admitted to the facility on [DATE] with pressure induced deep tissue damage of her right heel and a Stage 4 pressure ulcer of her sacrum. R2's Specialty Physician Initial Wound Evaluation & Management Summary dated 2/27/25 shows the wound physician's, V10, plan of care for R2's Stage 4 sacral pressure wound includes a low air loss mattress. R2's care plan initiated on 2/27/25 shows R2 has a low air loss mattress as an intervention for her Stage 4 pressure wound of her sacrum. On 5/5/25 at 10:18 AM, V2, was lying in bed watching TV. V2 did not have a low air loss mattress on her bed. When asked if she had a special mattress for her bed, V2 replied, No. On 5/5/25 at 1:25 PM, V4, Wound Care Nurse, said every…

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

Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) for 1 of 3 residents (R1) reviewed for infection control in the sample of 3. The findings include: R1's Order Summary Report dated 5/5/25 shows R1 has a current order for Enhanced Barrier precautions. R1's current care plan provided by the facility shows R1 has a Stage 4 pressure wound to her sacrum. On 5/5/25 at 9:56 AM, V4, Wound Care Nurse, V5, Certified Nursing Assistant (CNA), and V6, Life Enrichment were in R1's room assisting/changing R1's dressings. V6 was holding R1's leg, V5 was changing R1's left heel dressing. V5 assisted R1 to turn onto her side to allow visualization of R1's backside. V4, V5, nor V6 wore gowns while providing these direct cares. On 5/5/25 at 1:25 PM, V4 said residents with pressure wounds need to be on EBP. Staff should wear gowns and gloves while giving direct care to residents on EBP. On 5/5/25 at 1:42 PM, V3, Infection Prevention Nurse, said staff need to wear a gown, gloves, and mask when providing any close contact care to a…

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

Based on interview and record review the facility failed to ensure a residents-controlled medication was misappropriated. This applies to 1 of 10 residents (R1) reviewed for controlled medications in the sample of 10. The findings include: The Facility Reported Incident dated 4/28/25 states, Nurse (V4- Licensed Practical Nurse- LPN) wrote a statement stating she believed she threw the meds in the garbage. Writer looked through several garbage bags and was unable to locate the missing medication. Writer noted per narcotic sign out sheet that med was last administered 4/25/25 at 9:00 AM. Writer asked nurse if med was administered throughout her shift, and she stated yes. Writer asked why med was not signed out on MAR (Medication Administration Record) or paper record. Nurse stated she forgot and at this time she recorded administration. Nurse left the building at this time. This same document states, Cameras reviewed showing nurse in 200 preparing medications. Per video footage, nurse appears to empty bottle of tablets and toss the bottle in the garbage. On 4/30/25 at 10:00 AM V3…

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 the accurate reconciliation of a controlled substance. This applies to 1 of 10 residents (R1) reviewed for controlled substances in the sample of 10. The findings include: The Controlled Substance Proof of Use form for Bottle #2 shows 1 tablet removed from the bottle of 30 on 4/28/25, leaving 29 tablets. There is no time as to when this medication was administered and no signature from the person that administered it. The next entry is 4/28/25 at 9:30 PM given by V7 (Licensed Practical Nurse- LPN), leaving 28 tablets. R1's April MAR (Medication Administration Record) shows she has an order for Lorazepam 0.5 mg every 4 hours as needed for increased Anxiety. This document shows that V4 (LPN) signed out 1 tablet at 6:35 PM on 4/27/25 and V7 (LPN) signed out 1 tab at 9:30 PM on 4/28/25. There is no Lorazepam signed out on 4/28/25 prior to the 9:30 PM dose. On 4/30/25 at 12:05PM V4 stated, I might have given her another dose in the morning. When we counted in the morning there were 30 in the bottle. On 4/30/25 at 12:15 PM…

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 carry out a physician order for an Infectious Disease consultation for 1 of 3 residents (R2) reviewed for Quality of Care in the sample of 9. The findings include: On 1/8/25 at 10:45 AM, R2 was in bed and appeared drowsy and unable to stay awake during a conversation with this surveyor. Outside of R2's doorway was a sign indicating she (R2) is on contact isolation. R2's urinalysis report dated 12/19/24 shows her urine tested positive for ESBL (extended-spectrum beta- lactamases) via a urine culture that was completed on 12/22/24. A facility provided timeline for R2 shows R2 had a Urinary Tract Infection (UTI's) on 9/11/24 which did not require treatment. One 10/25/24 which required antibiotic usage and another on 12/19/24 which also required antibiotic treatment, with Ertapenm sodium solution for 7 days. On 1/8/25 at 11:44 AM, V4 (Nurse Practitioner) stated she had been monitoring R2's increase in UTI's and her recent diagnosis of ESBL in her urine and decided she should refer her to an Infectious Disease doctor for further…

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 notified in writing of a facility-initiated room change and failed to ensure the resident was shown the new room and introduced to her new roommate before the room change for 1 of 3 residents (R1) reviewed for room changes in the sample of 9. The findings include: R1's Census Report shows that she was transferred to another room on 11/25/24. On 12/4/24 at 9:30 AM, R1 stated that a male resident came into her room and kissed her on the cheek and after the facility heard about the incident, they made her change rooms so R2 could not find her. R1 stated that she was upset because she didn't understand why she had to change rooms when she did not do anything wrong. R1 stated that she really liked her previous room because she had a nice view out the window. R1 stated that after her room transfer, she did not get along with the other resident in the room due to her keeping her TV very loud. R1 stated that she could not hear her visitors nor her own TV. R1 stated, I feel like I am getting punished for what…

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

Based on observation, interview, and record review the facility failed to ensure a resident with wandering and aggressive behaviors was supervised and not allowed to enter other resident rooms for 1 of 1 resident (R2) reviewed for safety and supervision in the sample of 9. The findings include: On 12/4/24 at 9:45 AM, R2 was lying in bed. R2 was awake and speaking in Russian. On 12/4/24 at 1:13 PM, video footage from 11/24/24 was viewed. At 9:55 AM, R2 exited his room that is at the beginning of the hallway. R2 was walking independently. R2 walked about halfway down the hallway and entered a resident room at 9:57 AM. V8, Certified Nursing Assistant (CNA) went to the doorway of the room and R2 exited the room. R2 then proceeded down to the end of the hallway and V8 went in the opposite direction of R2. R2 then entered R1's room at 9:58 AM. At 9:59 AM, V6 (CNA) went into R1's room and came out of the room with R2. R2 then proceeded to walk the hallway. On 12/4/24 at 9:30 AM, R1 stated that a couple weeks ago (11/24/24) a man came into her room and placed his hands on her shoulders 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 transfer paperwork was sent to the hospital/emergency room for the correct resident for 1 of 3 residents (R2) reviewed for transfers in the sample of 3. The findings include: On 8/12/24 at 8:40 AM, V1 (Administrator) stated in March of 2024 R2 was sent to the hospital with R1's transfer paperwork. On 8/12/24 at 9:31 AM, V4 (Registered Nurse) stated she was the nurse taking care of R2 on 3/6/24 when R2 was sent to the hospital with R1's transfer paperwork. V4 stated R2 pulled out his gastrostomy tube (g-tube) and was sent to the emergency room to have it replaced. V4 stated about 20 minutes after R2 left the facility she received a phone call from an emergency room nurse saying R1 was in the emergency room. V4 stated she corrected the emergency room nurse and informed them that R2 and not R1was in the emergency room. According to V4, the emergency room nurse stated the transfer paperwork sent with R2 had R1's name on it. V4 stated V2 (Director of Nursing) was the one that printed the transfer paperwork for R2. 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.

Based on observation, interview, and record review the facility failed to store medications according to their policy and failed to ensure medication refrigerator temperatures were maintained. These failures have the potential to affect all residents in the facility. The findings include: The CMS 671 form dated 7/9/24 showed 91 residents reside in the facility. 1. On 7/10/24 at 12:11 PM, the 400-hall medication cart was reviewed with V9 (Registered Nurse) present. A box of liquid Norco (pain medication) and a box of liquid Lorazepam (antianxiety medication) were in the narcotic box. At 12:33 PM, the 200-hall medication cart was reviewed with V10 (LPN-Licensed Practical Nurse) present. A box of liquid Lorazepam was in the narcotic box. All three boxes were clearly labeled with stickers showing to store the medications in the refrigerator. 2. On 7/10/24 at 12:16 PM, the 200-hall medication cart was unlocked. This surveyor had full access to every drawer of medications (except the double locked narcotic box). The cart was parked directly next to a visitor/common use bathroom. Multiple…

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 MRR (Medication Regimen Review) was being completed by a licensed pharmacist on a monthly basis. This applies to 5 of 5 residents (R8, R26, R41, R56, and R61) reviewed for MRR's in the sample of 24. The findings include: R8's admission Record (Face Sheet) shows she was admitted to the facility on [DATE], with diagnoses to include type 2 diabetes mellitus, major depressive disorder, and hypertension. R8's only MRR for 2024 was in June. R26's admission Record (Face Sheet) shows she was admitted to the facility on [DATE], with diagnoses to include anxiety, depression, atrial fibrillation, and type 2 diabetes mellitus. R26's only MRR for 2024 was in July. R41's admission Record (Face Sheet) shows he was admitted to the facility on [DATE], with diagnoses to include bipolar disorder, hypertension, COPD (Chronic Obstructive Pulmonary Disease), and type 2 diabetes mellitus. R41's only MRR for 2024 was in June. R56's admission Record (Face Sheet) 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.

Based on interview and record review, the facility failed to obtain physician's orders for a resident (R67) code status for 1 of 1 resident reviewed for advanced directives in the sample of 24. The findings include: R67's electronic face sheet printed on 7/11/24 showed R67 has diagnoses including but not limited to Parkinson's without dyskinesia, unsteadiness on feet, repeated falls, lack of coordination, and syncope & collapse. R67's physician's orders for July 2024 showed no physician's orders for code status. R67's electronic medical record did not display his code status. R67's care plan dated 6/14/23 showed, Resident has following code: DNR .Note physician order and DNR is present on resident chart if applicable. R67's POLST (Physician's Orders for Life-Sustaining Treatment) dated 12/8/21 showed R67 has elected to be a DNR (Do Not Resuscitate). On 7/11/24 at 1:55PM, V9 (Registered Nurse) stated, If a resident has an emergency, I look at the banner on the resident profile in their EMR (electronic medical record). If it's not there, then I would go to their physician's orders. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a PASRR (Preadmission Screening and Resident Review) level 2 was completed on residents with serious mental illness. This applies to 2 of 2 residents (R66 and R41) reviewed for PASRR in the sample of 24. The findings include: R66's admission Record (Face Sheet) shows his diagnoses to include unspecified psychosis not due to a substance or known physiological condition, and anxiety. The same document shows R66 was admitted to the facility on [DATE]. R66's PASRR level 1, shows it was completed on 6/4/23, and shows no level 2 was required because there was no serious mental illness, intellectual disability, or developmental disability. On 07/10/24 at 12:10 PM, V5 (Admissions Director) stated, she was not aware that a PASRR level 2 should have been done if a resident has serious mental illness. V5 stated, she was never trained on how or when to request a level 2 PASRR. V5 stated, she is not a nurse and wouldn't know if a resident got a diagnosis of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide thorough incontinence care for a dependent resident. This applies to 1 of 2 residents (R37) reviewed for activities of daily living in the sample of 24. The findings include: R37's electronic face sheet printed on 7/11/24 showed R37 has diagnoses including but not limited to hemiplegia and hemiparesis, cerebral infarction, and dementia with behaviors. R37's facility assessment dated [DATE] showed R37 has severe cognitive impairment and is always incontinent of bladder. R37's care plan dated 6/23/23 showed, I have an ADL (activities of daily living) self-care performance deficit. I require assistance with ADL's because I have impaired balance, functional impairment in activity, hemiplegia, and general weakness. On 7/9/24 at 1:15PM, V14 (Certified Nursing Assistant) provided toileting assistance to R37. V14 removed 2 incontinence briefs from R37. V14 stated they put 2 incontinence briefs on R37 in case he urinates, and it leaks out…

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 fall prevention measures were in place for 2 of 11 resident's (R3, R30) reviewed for safety & supervision in the sample of 24. The findings include: 1) R3's electronic face sheet printed on 7/11/24 showed R3 has diagnoses including but not limited to congestive heart failure, left eye blindness, weakness, anxiety disorder, and altered mental status. R3's facility assessment dated [DATE] showed R3 has sever cognitive impairment and does not use alarms. R3's fall risk assessment dated [DATE] showed R3 is at risk for falls. R3's physician's orders dated 7/9/24 showed, clip alarm in place. R3's care plan dated 4/25/24 showed, The resident is at risk for falls related to incontinence. Clip alarm while in bed and wheelchair. On 7/9/24 at 10:16AM, R3 was laying in her bed with her alarm hooked to the right side of her bed. The end of the clip alarm was laying in the bed next to R3, not clipped to anything. V6 (Licensed Practical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen was administered at the physician prescribed rate and failed to handle oxygen tubing in a manner to prevent cross contamination for 1 of 1 resident (R36) reviewed for oxygen in the sample of 24. The findings include: R36's face sheet printed on 7/11/24 showed diagnoses including but not limited to heart disease, pleural effusion (buildup of excess fluid around the lungs), and pneumonia. R36's facility assessment dated [DATE] showed total staff dependence needed for toileting, hygiene, dressing, and transfers. The same assessment showed no cognitive impairment and frequently incontinent of urine and bowel. R36's July order summary report showed a physician order start dated 6/7/24 for: Oxygen at 2 liters per minute every shift. R36's care plan showed a focus area initiated 6/25/24 for oxygen therapy related to shortness of breath. Interventions included give medication as ordered by physician and oxygen at 2 liters per NC…

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 initiate isolation precautions for a resident (R56) with a wound and peripherally inserted central catheter (PICC) lined, failed to perform hand hygiene before and after catheter care for a resident (R248), and failed to wear personal protective equipment for a resident (R248) on enhanced barrier precautions. These failures apply to 2 of 7 residents reviewed for infection control in the sample of 24. The findings include: 1) R56's electronic face sheet printed on 7/11/24 showed R56 has diagnoses including but not limited to dementia with behaviors, sciatica, bipolar disorder, anemia, pressure ulcer of left hip-unstageable, non-pressure chronic ulcer of left buttock, history of urinary tract infections, and anxiety disorder. R56's facility assessment dated [DATE] showed R56 has no cognitive impairment. R56's physician's orders for July 2024 showed no orders for R56 to be on enhanced barrier precautions. R56's wound assessment dated [DATE]…

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

Based on observation, interview, and record review the facility failed to transfer a resident according to the resident's care plan. This failure applies to 1 of 5 residents (R1) reviewed for falls in the sample. The findings include: On 04/24/24 at 10:33AM, R1 was in her room sitting in a wheelchair. R1 had two staples in the top posterior area of her head. On 04/24/24 at 10:33AM, R1 stated, I cannot remember what happened. On 04/24/24 at 10:40AM, V8 R1's family stated, my sister and I were concerned about the staff using a mechanical stand lift for the transfer. My mom does not use a mechanical lift. On 04/24/24 at 2:49PM, V3 ADON-Assistant Director of Nursing stated, R7 CNA-Certified Nursing Assistant reported that the resident was weaker that night and needed the mechanical stand lift. The CNA did not use the mechanical stand lift appropriately. The mechanical stand lift is not part of R1's plan of care. The CNA should not have used the mechanical stand lift. R7 CNA should have reported to the nurse before attempting the transfer. On 04/25/24 at 10:30AM, V9 Restorative CNA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement dressing change orders for a resident admitted with an open wound. This applies to 1 of 4 residents (R501) reviewed for pressure/treatment interventions in the sample of 6. The findings include: On 5/6/2024 at 9:33AM, R501 stated she was admitted in the last two weeks and came in with a wound on her backside. On 5/6/2024 at 10:25AM, R501 stated she is unsure when the dressing change was started after she was admitted to the facility. On 5/6/2024 at 12:16PM, V7 Wound Care Nurse stated he was not told about the resident's wound upon admission. V7 stated if a wound is identified by the admitting nurse, they can call the primary physician and have orders placed for the resident until the wound doctor rounds on the patient. On 5/6/2024 at 12:47PM, V4 Registered Nurse (RN) stated she took care of R501 on 4/27/2024 and 4/28/2024. V4 stated she did not do a dressing change on R501 because there was no order to do one on the Treatment…

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 Activities of Daily Living (ADL) assistance for residents requiring extensive assistance for two of three residents (R6, R5) reviewed for ADLs in the sample of eight. The findings include: 1. R6's admission Record shows he was admitted to the facility on [DATE], with diagnoses including lack of coordination, low back pain, non-pressure ulcer of buttock, restlessness and agitation, anxiety disorder, major depressive disorder, and repeated falls. R6's Care Plan shows R6 requires total dependence with bed mobility and toileting and had urinary incontinence and needs assistance from staff. R6's MDS (Minimum Data Set) dated September 28, 2023, shows R6 is not cognitively intact. On December 26, 2023, at 12:13 PM, V9 CNA (Certified Nursing Assistant) and V12 (Licensed Practical Nurse) performed incontinence care to R6. There was a strong urine smell. R6 had two incontinence briefs on that were saturated with dark urine from front 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 physician ordered treatments were in place to non-pressure wounds for two of three residents (R3, R1) reviewed for non-pressure wounds in the sample of eight. The findings include: 1. R3's Order Summary Report dated December 27, 2023, shows R3 was admitted to the facility on [DATE], with diagnoses including idiopathic urticaria, urinary tract infection, anxiety disorder, and hemiplegia. An order for Bilateral buttock: Cleanse with normal saline, allow to air dry, apply hydrocolloid sheet to irritated area every night shift for skin integrity was entered on December 22, 2023. On December 26, 2023, at 11:07 AM, R3 buttocks was red with scratches and open areas throughout her buttocks area. R3 said her buttocks was painful. There was no dressing on R3's buttocks. R3's Resident Skin Check dated December 26, 2023, shows she has dryness, scratches, and a rash to her buttocks. R3's Treatment Administration Record dated December 1,…

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 perform incontinence care in a manner to prevent urinary tract infections for one of three residents (R6) reviewed for incontinence care in the sample of eight. The findings include: R6's admission Record shows he was admitted to the facility on [DATE], with diagnoses including lack of coordination, low back pain, non-pressure ulcer of buttock, restlessness and agitation, anxiety disorder, major depressive disorder, and repeated falls. R6's Care Plan shows R6 requires total dependence with bed mobility and toileting and has urinary incontinence and needs assistance from staff. R6's MDS (Minimum Data Set) dated September 28, 2023, shows R6 is not cognitively intact. On December 26, 2023, at 12:13 PM, V9 CNA (Certified Nursing Assistant) and V12 (Licensed Practical Nurse) performed incontinence care to R6. There was a strong urine smell. R6 had two incontinence briefs on that were saturated with dark urine from front to back. R6 was laying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a physician ordered antibiotic for one of three residents (R1) reviewed for medications in the sample of eight. The findings include: R1's Order Summary Report shows she was admitted to the facility on [DATE] with diagnoses including history of falling, urinary tract infection, non-pressure chronic ulcer of other part of right foot, non-pressure chronic ulcer of other part of left foot, non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle, non-pressure chronic ulcer of other part of right foot with necrosis of bone, non-pressure chronic ulcer of other part of right foot with necrosis of muscle, and local infection of the skin and subcutaneous tissue. On December 26, 2023, at 2:18 PM, V15 (R1's Power of Attorney/granddaughter) said that the facility took R1 to a foot doctor appointment on December 12, 2023. V15 said R1's foot doctor called her on December 15, 2023, and told her that R1 needed to be on Bactrim (antibiotic)…

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 its abuse policy to ensure staff received abuse training. This failure has the potential to affect all 77 residing in the facility. The findings include: The facility provided roster on 10/16/23 shows there were 77 residing in the facility. A facility reported State of Illinois Serious Injury Incident and Communicable Disease Report form shows on 9/17/23 R3's son (V11) reported an incident that occurred on 9/16/23 where R3 received poor care from a CNA who was determined to be V25 (Agency CNA). On 10/16/23 at 11:30 AM, V1 (Administrator) said she investigated the abuse incident involving R3 and substantiated verbal abuse. She said the CNA (V25) was from an agency. On 10/18/23 at 8:50 AM, V1 said the facility does not provide abuse training to agency staff. They only provide a basic orientation to the building. V1 said the facility has a corporate contract with an agency and assumes they provide training. On 10/18/23 at 12:40 PM, V26 (Quality Associate from agency) said their agency consists of independent contractors…

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 fall interventions were implemented for a resident (R4) with history of falls for 1 of 7 residents (R4) reviewed for falls in the sample of 13. The findings include: On 10/16/23 at 9:27 AM, R4 was in bed sleeping. R4's call light was clipped to the quarter side rail with the touch pad at the end of the cord tucked down between the mattress and the rail. R4's wheelchair was at the foot of the bed. R4's bedside table with food and personal items was approximately 3 feet away from R4's bed (not within reach). On 10/16/23 at 9:30 AM, V4 Registered Nurse said R4 is a fall risk and has had several falls from trying to get up by herself. On 10/16/23 at 10:28 AM, V5 Certified Nursing Assistant said R4 is a fall risk and has sight impairment and at times some confusion. V5 said R4 should have a clip alarm on her wheelchair but was not sure about fall interventions when in bed. On 10/16/23 at 10:38 AM, V2 Director of Nursing (DON) said when a resident falls and investigation is done to determine root cause. V2…

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 R1 received physician ordered interventions to reduce pressure ulcer development. This applies to one of three residents (R1) reviewed for improper nursing care in the sample of three. The findings include: On 08/14/23 at 10:12AM, R1 was lying in bed. R1 did not have an air pressure reduction mattress. R1's right and left heels were resting on the bed. R1's heel protectors were on the floor next to R1's bed. On 08/14/23 at 10:12AM, R1 said, I am supposed to wear my heel boots in bed. The staff forget to put them on. On 08/14/23 at 10:27AM, V6 CNA-Certified Nursing Assistant said, R1 should have her heel protectors on when in bed. R1 is not on an air mattress. R1's Physicians Orders on 08/14/23 shows, ensure heel protectors are on resident's bilateral feet at all times while in bed, order start date 07/09/23. Order air mattress for skin integrity impairment prophylaxis, order start date 07/19/23. The facility's Pressure Injury Prevention Guidelines dated 11/01/22 shows, interventions will be implemented…

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 R2 received her meal in a form that met her needs, for one of three residents reviewed for special diets in the sample of three. The findings include: R2's Medical Record on 08/14/23 shows, multiple diagnoses including malnutrition. On 08/14/23 at 12:00PM, R2 had a slice of ham on her plate. R2 stabbed the ham with a fork and placed it in her mouth. After R2 chewed on the ham slice she spit the chewed-up ham out of her mouth and onto her plate. R2 repeated this process with each bite of ham. On 08/14/23 at 12:01PM, V3 [NAME] said, if the diet order shows mechanical soft the meat should be ground. The Certified Nursing Assistance passes the meal trays to the residents. R2's Physicians Order on 08/14/23 shows, NAS (No Added Salt) diet, Mechanical Soft texture, Regular consistency, order start date 01/31/23. The facility's undated Therapeutic Diet Orders policy shows, therapeutic diets, including mechanically altered diets where Appropriate, will be based on the resident's individual needs as determined by…

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

Based on observation, interview and record review the facility failed to provide sufficient nursing staff to meet the needs of the residents. This failure has the potential to affect all 77 residents in the facility. The findings include: The Facility Data Sheet dated August 7, 2023, showed a resident census of 77. On August 7, 2023, at 9:23 AM, R2 was seated in her room. R2's hair was not combed. R2's hair appeared greasy. R2 stated, I haven't had a shower in a long time. I don't know when the last time I had one. They don't have enough staff so I can't get them. I can't shower by myself. R2's shower records dated June 1, 2023-August 7, 2023, were reviewed. The records showed R2 received 2 showers in June (6/14/23, 6/26/23). The records showed R2's last shower was July 24, 2023. The records showed R2 had not received any showers August 1-6, 2023. On August 7, 2023, at 1:00 PM, V12 Family of R1 stated he was concerned R1 was not getting showered or walked due to a lack of staff. V12 stated, They have been short-staffed for awhile. We have even heard the staff complaining about being…

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 resolve a family's concern/grievance, involving a facility resident, in a timely manner for 1 of 3 residents (R1) reviewed for grievances in the sample of 4. The findings include: R1's current care plan showed R1 was cognitively impaired related to her diagnosis of dementia. R1's care conference note dated June 6, 2023, showed a care plan meeting was held with facility staff and R1's power of attorney/family member (V12) in attendance. The note showed, Family concerns: 1. wants (R1) to continue physical therapy. 3. Continue to encourage participation in activities and moving around. On August 7, 2023, at 1:00 PM, V12 (Family of R1) stated, We had a care plan meeting in June (2023) for (R1). One of my concerns that I voiced was that (R1) was not being walked or being exercised. I want her up and moving around as much as she can. I am concerned she is getting weaker. We (R1's children) visit (R1) daily. We never see her up walking or out of her wheelchair. I asked for her to be re-evaluated by therapy, to see if she qualified…

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 showering/bathing assistance to residents who need extensive assistance with activities of daily living (ADLs) for 2 of 4 residents (R1, R2) reviewed for activities of daily living in the sample of 4. The findings include: 1. R2's resident assessment dated [DATE], showed R2 required the extensive assistance of one staff for bathing/showering. On August 7, 2023, at 9:23 AM, R2 was seated in her room. R2's hair was not combed. R2's hair appeared greasy. R2 stated, I haven't had a shower in a long time. I don't know when the last time I had one. They don't have enough staff so I can't get them. I can't shower by myself. R2's shower records dated June 1, 2023-August 7, 2023, were reviewed. The records showed R2 received 2 showers in June (6/14/23, 6/26/23). The records showed R2's last shower was July 24, 2023. The records showed R2 had not received any showers August 1-6, 2023. 2. R1's resident assessment dated [DATE], showed R1…

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 restorative therapy services, including walking and range of motion (ROM) exercises, to residents with limited range of motion for 2 of 2 residents (R1, R3) reviewed for restorative/ROM services in the sample of 4. The findings include: 1. R1's Physical Therapy Discharge summary dated [DATE], showed R1 had been discharged from physical therapy. R1's Restorative Observations form dated May 30, 2023, showed R1 had limited ROM to her bilateral arms, hands, legs, and feet. On August 7, 2023, at 1:00 PM, V12 (Family of R1) stated, We had a care plan meeting in June (2023) for (R1). One of my concerns that I voiced was that (R1) was not being walked or being exercised. I want her up and moving around as much as she can. I am concerned she is getting weaker. We (R1's children) visit (R1) daily. We never see her up walking or out of her wheelchair. I asked for her to be re-evaluated by therapy, to see if she qualified for physical therapy…

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 attempt gradual dose reductions for psychotropic medications and failed to ensure their was a duration ordered for as needed anti-anxiety medications for 4 of 5 residents (R7, R35, R43 and R68) reviewed for unnecessary medications in the sample of 18. The findings include: 1. R35's June Physician's Order Sheet shows an order for Risperidone (anti-psychotic) 1 milligram (mg) at bedtime for anxiety. R35's Consultant Pharmacist Recommendation to Physician Form printed on 4/20/23 shows, Federal Guidelines state antipsychotic drugs should have an attempt at gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least one month between attempts, then annually thereafter. This resident has been taking Risperidone 1 mg hs (bedtime) since 9/2022 without a GDR. Could we attempt a dose reduction at this time to Risperidone 0.75 mg to verify this resident is on the lowest possible dose? If not, please indicate response below. The response section of the form is not filled out by the physician. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide nail care and shaving assistance to residents who need extensive assistance with activities of daily living (ADLs) for 3 of 18 residents (R17, R25 and R67) reviewed for ADLs in the sample of 18. The findings include: 1. R17's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired and she requires extensive assistance with personal hygiene. On 06/12/23 at 9:41 AM, R17's fingernails on her left thumb and right fourth digit were 1/4 inch long and had brown debris under them. R17's fingernails on her first and second digit of her right hand had brown debris under them. R17 had scratch marks from itching on her bilateral thighs. R17 stated, Yes-those are pretty long and dirty. 2. R67's Minimum Data Set assessment dated [DATE] shows that she is totally dependant on staff for personal hygiene. On 6/12/23 at 9:59 AM and 6/13/23 at 8:54 AM, R67's fingernails were long and painted. The underside of R67's fingernails had…

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 wound dressing was in place as prescribed by the physician. This applies to 1 of 4 residents (R66) reviewed for pressure ulcers in the sample of 18. The findings include: R66's electronic medical record lists her diagnoses to include: Alzheimer's Disease, type II diabetes mellitus, seizures, diastolic (congestive) heart failure, pressure ulcer of sacral region, unstageable, pressure ulcer of right buttock, stage 3, pressure ulcer of left buttock, stage 3, protein-calorie malnutrition, pressure ulcer of left heel, unstageable, diarrhea, and methicillin resistant staphylococcus aureus infection (MRSA infection). R66's wound evaluation and management summary by the wound physician dated June 5, 2023 shows, Site 1: Stage 4 pressure wound sacrum full thickness: Wound size (L x W x D): 8.0 X 4.5 X 2.0 cm (centimeters), Wound progress: deteriorated due to generalized decline of patient . Additional would detail: Pt (Patient) 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 a resident with limited range of motion and a contracture, received Passive Range of Motion (PROM) and splint application for 1 of 2 residents (R25) reviewed for Range of Motion in the sample of 18. The findings include: On 6/12/23 at 11:14 AM, R25 was laying in bed. R25 said that he has had multiple strokes and can not move his left upper or lower extremity. R25's left wrist was contracted. R25's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: monoplegia of upper limb following cerebral infarction affecting left non-dominant side and cerebral vascular disease. R25's Occupational Discharge Summary shows that he was discharged from therapy on 4/12/23. The summary shows a goal of, Patient will be able to tolerate resting hand splint for 2 hours on his L (left) hand. This goal was met on 4/4/23. The summary shows, Patient Progress: Patient responded positively to passive techniques to stimulate functional…

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 label the enteral feeding administration set (formula receptacle and tubing) and syringe for 1 of 3 residents (R64) reviewed for tube feeding in the sample of 18. The findings include: On 6/12/23 at 10:05 AM, R64 was lying in his bed watching TV. R64's enteral feeding bag/tubing was hanging on a pole and was not labeled. There was no resident name, time, date, nurse initials, or description of the contents indicated on the feeding administration set. A [NAME] syringe was inside a graduated cylinder located on R64's bedside stand with no date on either of them. On 6/13/23 at 9:04 AM, V6, Licensed Practical Nurse (LPN), said when the nurse hangs a new bag (of enteral feeding liquid), she is supposed to date and time it with their initials. V6 said a bag is good for 24 hours and then must be replaced with a new bag. V6 said the [NAME] syringe needs to be changed every 24 hours too. R64's admission Record dated 6/13/23 shows his diagnoses…

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 monitored during medication administration for 1 of 18 residents (R280) reviewed for medication administration in the sample of 18. The findings include: On June 12, 2023 at 9:44 AM, R280 was sitting in her wheelchair in her room watching TV, with her over bed table next to her. Two albuterol inhalers, a tube of nystatin and triamcinolone acetonide cream, a bottle of antifungal powder, and a bottle of artificial tears were on R280's bedside table. R280 said she uses the medications when she needs them. On 6/13/23 at 8:54 AM, V6- Licensed Practical Nurse (LPN), said no residents in the facility self-administer their medications. V6 said residents can only keep medications at the bedside with a physician's order. R280's admission Record dated 6/13/23 shows R280's diagnoses include, but are not limited to, polyneuropathy, hemiplegia and hemiparesis following cerebral infarction, asthma, and depression. R280's Order Summary Report, dated 6/13/23, does not show an order for R280 to be able to…

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

Based on observation, interview, and record review, the facility failed to ensure adaptive eating utensils were provided for 1 of 18 residents (R36) reviewed for assistive devices in the sample of 18. The findings include: On 6/12/23 at 11:56 AM, R36 was in the dining room for lunch. R36 said he can't eat because he needs a special spoon. R36's meal ticket on his lunch tray listed under Adaptive equipment a plate guard and build up foam utensils. R36's plate had no plate guard and he did not have a foam knife or spoon. On 6/12/23 at 12:03 PM, R36 was eating his beef stroganoff and mixed vegetables with his hands. When asked if he needed help, R36 said he needs a spoon. On 6/12/23 at 12:07 PM, Surveyor 40798 approached V5, Dietary Manager, to inquire if R36 required adaptive equipment to eat. V5 said R36 needs a big spoon. V5 came out to the dining area and told R36 to stop eating with his fingers and use his fork. R36 told V5 he wants a spoon. On 6/13/23 at 2:09 PM, V2, Director of Nursing (DON), said if a resident requires an adaptive device, dietary puts it on their tray. 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 to have an Infection Control Preventionist on staff which affects all 76 residents in the facility. The findings include: The Resident Census and Conditions form (672) dated March 29, 2022 showed the facility census was 76 residents. On March 28, 2022 at 12:35 PM V3 (Executive Director) stated the previous Infection Control Preventionist's (ICP) last day of work was November 17, 2022. The facility currently has no nurses with the completed ICP certification. The facility's COVID-19 testing policy dated March 23, 2021 showed Rolling Hills employs a designated full time Infection Control Nurse. The responsibility of the Infection Control Nurse is to plan, develop, organize, implement, evaluate, and direct Safety / Infection Control care services, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern nursing care facilities.

Based on interview and record review the facility failed to ensure pharmacy recomendations were forwarded to the facilty in a timely manner, failed to notify the physician of irregularities of medication regimen in a timely manner and failed to develop a policy that included a timeframe for the different steps in the review process for 4 of 7 residents (R7, R16, R74 and R76) reviewed for Medication Regimen Review (MRR) in the sample of 18. The findings include: 1. R76's MRR dated 1/14/22 shows a recommendation for Quetiapine 25mg BID (twice a day) PRN (as needed). The report says, PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident in person for the appropriateness of renewal. There is a stamp on the paper that shows that they recieved the report on 2/11/22. The report does not show a presciber's response. On 3/29/22 at 2:07 PM, V2 (Director of Nursing) said that she recieved the report on 2/11/22 but has not done anything with it yet. V2 said, It must have got missed. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a physician assessed a resident every 14 days for the continued need for an as needed (PRN) anti-psychotic medication and failed to have a duration/stop date for a resident on a PRN anti-anxiety medication for 4 of 7 residents (R7, R16, R74 and R76) reviewed for psychotropic medications in the sample of 18. The findings include: 1. R76's Physician's Order Sheet printed on 3/29/22 shows and order dated 1/10/22 for, Quetiapine Fumarate (anti-psychotic) 25 milligrams (mg) by mouth twice a day as needed. R76's Medication Regimen Review dated 1/14/22 shows a recommendation for Quetiapine 25 mg BID (twice a day) PRN. The report says, PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident in person for the appropriateness of renewal. R76's Clinical Records show that she was re-admitted to the facility on [DATE] and did not see an attending…

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 nail care was provided for 2 of 18 residents reviewed for activities of daily living in the sample of 18. The findings include: 1. On 03/28/22 at 11:00 AM, R16 had long dirty finger nails with brown debris underneath. On 03/29/22 at 01:00 PM, R16's nails were still long with visible brown debris underneath. On 03/30/22 at 9:48 AM, V2 Director of Nursing stated nail care happens on the weekends, but if staff sees a need during the week, they should take care of the nails as needed. R16's Minimum Data Set, dated [DATE] shows R16 requires extensive assistance for personal hygiene. 2. On 03/28/22 at 9:57 AM, R34 had long, jagged finger nails of various lengths. On 03/29/22 at 09:25 AM, R34 was feeling his nails and stated my nails need to be trimmed a little. Some are rough. The girl will do it whenever she gets around to it, I can't do it myself. R34's Minimum Data Set, dated [DATE] shows R34 is cognitively intact and requires limited…

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 a contracture had a brace for 1 of 4 residents (R41) reviewed for contractures in the sample of 18. The findings include: On 03/28/22 at 11:50 AM, R41's right hand was partially contracted with the pinky finger bent up toward the palm of his hand. R41 stated they lost my brace for my hand. I'm supposed to wear it at nights. When I moved to isolation during lockdown, it got lost. I spoke with therapy and social services about it, and it's been a month now I still don't have it. On 03/29/22 at 01:05 PM, V5 Director of Therapy stated R41 has a brace that he wears at night. It was reported something like a month ago, that it was missing. We were notified, we looked all over and let social services know. The facility's Quality Improvement Form dated 3/18/22 shows notified of R41 missing a hand/wrist black brace with blue Velcro. R41 stated that he last remembers having it in his room on 200 hall (COVID unit). On 03/29/22 at 01:18 PM, V6 Director of Social Services stated I'm aware R41's brace…

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 use a gait belt to safely transfer a resident and failed to ensure a resident was able to safely wash their hands for 2 of 18 residents (R4 and R56) reviewed for safety in the sample of 18. The findings include: R4's Minimum Data Set assessment dated [DATE] shows that she needs assistance of one person for toilet use and is not steady when moving on and off of the toilet. 1. On 3/28/22 at 12:50 PM, V11 (Resident Helper) brought R4 into the bathroom. With no gait belt on R4, V11 assisted R4 from her wheelchair to the toilet. V11 then assisted her back to her wheelchair by lifting under R4's armpit and guiding her hips into the wheelchair. On 3/29/22 at 1:13 PM, V12 (Certified Nursing Assistant) said that gait belts should be used on all assisted transfers for the resident's safety. R4's Basic Needs Care Plan shows, I use the bathroom with extensive assistance of 1 using walker and gait belt. The facility's undated Gait Belt Transfers Policy…

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 thorough incontinence care for 1 of 2 residents (R11) reviewed for incontinence care in the sample of 18. The findings include: On 03/28/22 at 10:33 AM, V8 Certified Nursing Assistant (CNA) removed a urine soaked brief from R11 and assisted R11 to sit on the toilet. When R11 was done, V8 wiped R11's rectal area with wet disposable towels and stool was visible on the towel. V8 wiped R11's rectal area a second time with the towels and stool was visible on the towel. Without cleaning R11's peri area or wiping R41's rectal area until no stool present on towel, V8 applied a new brief and pulled up R11's pants. On 03/30/22 at 9:48 AM, V2 Director of Nursing said after a resident was incontinent of urine and stool the residents whole area should be cleaned, peri area included, wiping dirty to clean. R11's Minimum Data Set, dated [DATE] shows R11 requires extensive assistance of two persons for toileting and is always incontinent of bowel…

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 nutritional supplement was given to a resident who had a significant weight loss for 1 of 4 residents (R4) reviewed for weight loss in the sample of 18. The findings include: R4's Weight Report printed on 3/29/22 shows that on 2/7/22, R4 was 118.2 pounds and on 3/7/22 she was 110.6 pounds. A 6.43% loss in 1 month. R4's Physician's Order Sheet shows an order dated 11/3/21 for, Meal supplement: Resource Juice 1 brick/carton lunch supper. On 3/29/22 at 12:45 PM, R4 had completed lunch and no resource juice was provided. On 3/29/22 at 12:45 PM, V4 (Licensed Practical Nurse) said that if resource juice is ordered, it is put on the resident's tray by the kitchen staff. V4 said that she does not know why R4 did not get resource juice on her tray. R4's Nutrition Care Plan shows, I need dietary staff to-provide me with Provide resource juice q (every) lunch .for additional nutrition.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to serve a mechanical soft diet to a resident as ordered for 1 of 18 residents (R3) reviewed for diets in the sample of 18. The findings include: R3's Face Sheet shows that he was admitted to the facility on [DATE]. R3's New admission Notification Form dated 3/16/22 shows a diet consistency of mechanical soft. R3's admission Assessment and Baseline Care Plan dated 3/16/22 shows, Dietary Instructions: Low Concentrated Sweets/No Added Salt/Mechanical Soft consistency with thin liquids. R3's Physician's Order shows that R3 was ordered a regular consistency diet on 3/16/22. The diet was changed to mechanical soft consistency on 3/25/22. On 3/28/22 at 11:50 AM, V9 (R1's spouse) said that she has been asking for grinded food for weeks and R1 keeps getting regular food. V9 said that R3 has a hard time chewing due to ill fitting dentures. V9 said that she has told multiple people that R3 needs R3 diet changed. On 3/28/22 at 12:00 PM, V10, Certified…

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