Lincolnshire Health & Rehabilitation Center

Based on observation, record review and interview, the facility failed to ensure proper medication storage related to insulin pens not labeled when opened, and loose pills observed in the medication carts for 1 of 2 units (A Wing) and medications at the bedside for residents who did not self-administer medications. (Residents G, 71)Findings include: 1. During an observation on 11/18/2025 at 1:12 p.m., the C hall medication cart on the A Wing was observed with LPN 4. There were many loose pills in all of the medication drawers. During an interview at that time, LPN 4 was unaware there were loose pills in the cart. 2. During an observation on 11/18/2025 1:16 p.m., the B hall medication cart on the A Wing was observed with LPN 4. There were many loose pills in all the drawers. There was one opened multiuse vial of Humulin Regular insulin with no date. There was one opened Lantus insulin pen with date opened. There was one opened multiuse vial of Lantus insulin with an open date of 10/8/25. During an interview at that time, LPN 4 indicated she was aware the insulin vials and pens should…

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, record review and interview, the facility failed to follow the recipe for pureed spinach. This had the potential to affect the 5 residents who received a pureed diet. Finding includes:During a meal preparation observaton on 11/20/25 at 10:30 a.m., Dietary [NAME] 2 was observed preparing pureed spinach. He placed six scoops (1/2 cup) of cooked spinach into the blender and started the machine. He stopped the blender, stirred the spinach, and added an unmeasured amount of chicken broth into the blender. He started the machine again to mix it together. The cook stopped the machine, stirred the spinach and added more chicken stock, again it was not measured. He blended the spinach and stopped the machine again, removed the lid and stirred the mixture. He then added an unmeasured amount of the product Thick and Easy (a food thickening agent) to the spinach, turned the machine back on and blended it together. He continued to blend and stir the mixture three more times with adding an unmeasured amount of the food thickening agent. He poured the pureed spinach into 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 observation, record review, and interview, the facility failed to ensure residents were assessed for self-administration of medications and had a physician's order to self-administer medications, for 1 of 1 resident reviewed for self-administration of medication. (Resident 59) Finding includes:On 11/17/25 at 2:58 p.m., a bottle of nasal spray was observed on the resident's over bed table. Clotrimazole ointment was observed on the resident's nightstand. On 11/18/25 at 8:54 a.m., refresh eye drops and a bottle of nasal spray were observed on the resident's over bed table. Clotrimazole ointment and Neosporin ointment were observed on the resident's nightstand. On 11/20/25 at 10:10 a.m., refresh eye drops and a bottle of nasal spray were observed on the over bed table. Clotrimazole ointment was observed on the resident's nightstand. The resident's record was reviewed on 11/19/25 at 2:31 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, congestive heart failure, and hypertension. The Annual Minimum Data Set (MDS) assessment, dated 9/15/25, indicated 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 observation, record review and interview, the facility failed to ensure the call light was in reach for 1 of 14 active residents reviewed who were able to use the call light. (Resident 71)Finding includes:During random observations on 11/17/25 at 12:50 p.m., 11/19/25 at 9:13 a.m. and 9:50 a.m., 11/20/25 at 9:50 a.m. and 1:51 p.m., and 11/21/25 at 9:42 a.m., Resident 71 was sitting in his wheelchair next to his bed. His call light pad was clipped onto its cord on the wall, on the opposite side of the bed. The resident's record was reviewed on 11/20/25 at 11:20 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), diabetes, and left below the knee amputation. The Quarterly Minimum Data Set (MDS) assessment, dated 10/21/25, indicated the resident was cognitively intact for daily decision making, and required moderate assist with activities of daily living (ADLs). During an interview on 11/21/25 at 1:09 p.m., the Director of Nursing (DON) indicated the resident was able to use the call light, and it should have been kept in his reach.…

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, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to visual impairment for 1 of 1 resident reviewed for sensory / communication. (Resident F)Finding includes:During a random observation on 11/17/25 at 10:40 a.m., Resident F was observed in bed with a blanket pulled over his head and his television on. He indicated he kept his head under the blanket because it was comfortable, and he could not see the television anyway because he was blind. The record for Resident was reviewed on 11/19/25 at 10:03 a.m. Diagnoses included, but were not limited to, heart failure, pain, and vascular dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 8/11/25, indicated the resident had severe cognitive impairment, was dependent in activities of daily living (ADLs) and had adequate vision.An Interdisciplinary Team Note, dated 6/9/25, indicated a contributing factor to the resident's recent fall was their vision impairment. A Physician's History and Physical, dated 4/21/25,…

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, record review, and interview, the facility failed to ensure a dependent resident received assistance with activities of daily living (ADL's) related to nail care for 1 of 5 residents reviewed for ADL's. (Resident C)Finding includes:On 11/17/25 at 10:20 a.m., Resident C was observed lying in bed. Her fingernails were jagged and uneven with dark debris underneath. On 11/18/25 at 10:00 a.m., Resident C was observed lying in bed. Her fingernails were jagged and uneven with dark debris underneath. Resident C's record was reviewed on 11/19/25 at 9:51 a.m. Diagnoses included, but were not limited to, dementia, diabetes, and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 11/5/25, indicated the resident was mildly cognitively impaired and was dependent on staff for assistance with bathing and personal hygiene. A Care Plan, updated 6/26/25, indicated the resident required assistance with ADLs. The interventions included to assist with personal hygiene including dressing and grooming as needed. A Care Plan, updated 10/7/25, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents received foot care and had routine visits with a podiatrist related to long and thick toenails for 3 of 5 residents reviewed for ADL's (activities of daily living). (Residents C, 33, and G)Findings include:1. On 11/17/25 at 11:00 a.m., Resident C was observed lying in bed. Her toenails were long and thick. There was a dried dark red substance under her left great toenail. Her feet were scaly and dry. On 11/18/25 at 10:00 a.m., Resident C was observed lying in bed. Her toenails were long and thick. There was a dried dark red substance under her left great toenail. Her feet were scaly and dry. Resident C's record was reviewed on 11/19/25 at 9:51 a.m. Diagnoses included, but were not limited to, dementia, diabetes, and hypertension. The resident was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment, dated 11/5/25, indicated the resident was mildly cognitively impaired and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide treatment for limited range of motion related to splints not in place and lack of instructions for use of a splint for 3 of 4 residents reviewed for range of motion. (Residents 1, E, and F)Findings include: 1.On 11/17/25 at 3:00 p.m., Resident 1 was observed lying in bed. His left hand was in a fist and there was no splint in place. The resident indicated staff didn't usually put anything on or in his hand. On 11/18/25 at 8:55 a.m. Resident 1 was observed lying in bed. His left hand was in a fist and there was no splint in place. On 11/20/25 at 10:31 a.m. Resident 1 was observed lying in bed. His left hand was in a fist and there was no splint in place. Resident 1's record was reviewed on 11/21/25 at 12:54 p.m. Diagnoses included, but were not limited to, congestive heart failure, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and left side hemiplegia. The Quarterly Minimum Data Set assessment (MDS), dated…

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, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 4 residents reviewed for accidents. (Resident 60)Finding includes:On 11/17/25 at 2:54 p.m., Resident 60 was observed getting out of bed unassisted. She had on non-skid socks and pushed her wheelchair to the bathroom. There were no non-skid strips on the floor by her bed.On 11/18/25 at 11:51 a.m., Resident 60 was lying in bed. There were no non-skid strips on the floor by her bed, and the bed was not in the lowest position.On 11/20/25 at 10:29 a.m., Resident 60 was lying in bed. There were no non-skid strips on the floor by her bed, no Dycem (anti-slip material) to her wheelchair seat, and no anti-tippers to her wheelchair.Record review for Resident 60 was completed on 11/19/25 at 3:25 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertension, and nontraumatic subarachnoid hemorrhage.The Quarterly Minimum Data Set (MDS) assessment, dated 10/30/25, indicated the resident was cognitively intact.…

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

Based on observation, interview, and record review, the facility failed to ensure an urinary indwelling catheter collection bag was maintained below the level of the bladder for 1 of 3 residents reviewed for urinary catheters. (Resident 71)Finding includes: During random observations on 11/17/25 at 12:50 p.m., 11/19/25 at 9:13 a.m. and 9:50 a.m., 11/20/25 at 9:50 a.m. and 1:51 p.m., and 11/21/25 at 9:42 a.m., Resident 71 was sitting in his wheelchair next to his bed. The urine collection bag was hooked on the side of his wheelchair, near waist level. On 11/20/25 2:40 p.m., the resident was observed propelling himself in his wheelchair in the halls. The urine collection bag was hooked on the side of his wheelchair, near waist level. On 11/21/25 at 11:05 a.m., the resident was observed in the hallway, in his wheelchair. Multiple staff members walked by. The urine collection bag remained hooked on the side of his wheelchair, near waist level. The resident's record was reviewed on 11/20/25 at 11:20 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease…

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, record review, and interview, the facility failed to ensure a resident was positioned with their head elevated while a tube feeding was infusing for 1 of 1 resident reviewed for tube feedings. (Resident E)Finding includes:During a random observation on 11/18/25 at 9:46 a.m., Resident E was observed lying nearly flat in bed. A tube feeding was infusing via a pump. Unit Manager 1 was immediately brought to the room. She stopped the tube feeding, repositioned the resident, elevated the head of the bed, and restarted the feeding. At that time, she indicated resident's head should be elevated at least 30 degrees while the tube feeding was infusing. The resident's record was reviewed on 11/18/25 at 3:09 PM. Diagnoses included, but were not limited to, Parkinson's, stroke, vascular dementia, and epilepsy.The 8/24/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, was dependent in activities of daily living (ADLs) and transfers.A Physician's Order, dated 4/11/23, indicated to elevate the head of the bed 30 to 45…

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 record review and interview, the facility failed to ensure an intravenous (IV) access site was assessed upon admission and removed in a timely manner for 1 of 1 resident reviewed for parenteral/IV fluids. (Resident D)Finding includes:The closed record for Resident D was reviewed on 11/19/25 at 3:22 p.m. Diagnoses included, but were not limited to, aortocoronary bypass graft, atherosclerotic heart disease, and type 2 diabetes mellitus. The Medicare 5-day Minimum Data Set (MDS) assessment, dated 8/9/25, indicated the resident had moderate cognitive impairment. The admission Nursing Assessment, dated 8/3/25, indicated the resident did not have an IV (intravenous) present. The After Visit Summary from the hospital, dated 8/3/25, had no documentation related to an IV access site. A Nurse's Note, dated 8/3/25 at 12:40 p.m., indicated the resident had multiple areas of small bruising related to IV insertion. The note did not indicate if the IV access was still present. A Nurse's Note, dated 8/4/25 at 9:49…

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, record review and interview, the facility failed to ensure residents received the necessary care and treatment related to oxygen administration for 2 of 3 residents reviewed for respiratory care. (Residents 1 and 9)Findings include:1. On 11/17/25 at 3:00 p.m., Resident 1 was observed lying in bed. A nasal cannula was in place and oxygen was flowing. The oxygen concentrator was set at 3.5 liters.On 11/18/25 at 8:55 a.m., Resident 1 was observed lying in bed. A nasal cannula was in place and oxygen was flowing. The oxygen concentrator was set at 3.5 liters.Resident 1's record was reviewed on 11/21/25 at 12:54 p.m. Diagnoses included, but were not limited to, congestive heart failure, chronic obstructive pulmonary disease (COPD), and atrial fibrillation.The Quarterly Minimum Data Set (MDS) assessment, dated 9/3/25, indicated the resident was cognitively impaired, dependent on staff for all activities of daily living (ADLs), and received oxygen therapy.A Care Plan, updated 12/4/25, indicated…

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 record review and interview, the facility failed to ensure blood pressure monitoring was completed for residents receiving blood pressure medications with parameters for 2 of 7 residents reviewed for unnecessary medications. (Residents H and D)Findings include:1.The record for Resident D was reviewed on 11/19/25 at 10:26 a.m. Diagnoses included, but were not limited to, Parkinson's disease and hypertension. The admission Minimum Data Set (MDS) assessment, dated 8/19/25, indicated the resident was moderately impaired for daily decision making. A Care Plan, dated 8/17/25, indicated the resident was at risk for complications secondary to the diagnosis of hypertension. Interventions included, but were not limited to, give anti hypertensive medications as ordered and obtain blood pressure readings as ordered or indicated. A Physician's Order, dated 8/12/25 and listed as current on the November 2025 Physician's Order Summary (POS), indicated the resident was to receive Losartan Potassium (a blood pressure medication) 100 milligrams (mg) daily for hypertension, hold if systolic…

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, record review, and interview, the facility failed to ensure a resident had a clean and homelike environment, related to a resident lying on soiled bottom sheet on the bed for 1 random observation. (Resident C) Finding includes: During an observation 7/7/25 at 9:47 a.m., Resident C was lying on her back in bed. She indicated she needed to be changed and that she was in a mess. The resident's skin was scaly and shedding from the shoulders and arms. There were several pieces of dry skin, dark specks and dark discoloration spots on the bottom sheet of the bed under the resident's arms. The resident indicated she had not had any care since last night. During an observation on 7/7/25 at 10:03 a.m., CNA 1 and CNA 2 entered the room to provide care to the resident. CNA 1 indicated the resident had a skin condition. When the top sheet was removed, the resident's skin on her torso and legs were also scaly and shedding. There was a copious amount of dried skin flakes and discoloration areas from her skin on the bottom sheet. CNA 2 indicated she had started her shift 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 observation, record review, and interview, the facility failed to ensure a comprehensive care plan was implemented for a resident with a skin condition for 1 of 4 resident care plans reviewed. (Resident C) Finding includes: During an observation 7/7/25 at 9:47 a.m., Resident C was lying on her back in bed. She indicated she needed to be changed and that she was in a mess. The resident's skin was scaly and shedding from the shoulders and arms. There were several pieces of dry skin, dark specks and dark discoloration spots on the bottom sheet of the bed under the resident's arms. During an observation on 7/7/25 at 10:03 a.m., CNA 1 and CNA 2 entered the room to provide care to the resident. CNA 1 indicated the resident had a skin condition. When the top sheet was removed, the resident's skin on her torso and legs were also scaly and shedding. There was a copious amount of dried skin flakes and discoloration areas from the skin on the bottom sheet. Resident C's record was reviewed on 7/7/25 at 1:46 p.m. The diagnoses included, but were not limited to, diabetes mellitus and…

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

Based on observation, record review, and interview, the facility failed to ensure a dependent resident received assistance with activities of daily living (ADLs) related to the timeliness of incontinence care for 1 of 3 residents reviewed for ADLs. (Resident C) Finding includes: During an observation 7/7/25 at 9:47 a.m., Resident C was lying on her back in bed. She indicated she needed changed and that she was in a mess and she had not had any care since last night. During an observation on 7/7/25 at 10:03 a.m., CNA 1 and CNA 2 entered the room to provide care to the resident. CNA 2 indicated she had started her shift at 7:00 a.m. and had not provided care to the resident prior to this observation. CNA 1 indicated the resident required assistance for bed mobility. There was a large amount of dried dark fluid with rings and reddish/pink drainage that covered the incontinent pad under the resident. The incontinent brief was saturated. CNA 2 indicated the resident's skin weeped and some of the drainage on the incontinent pad was from the skin. During the care, the resident moaned 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, record review, and interview, the facility failed to ensure treatments for pressure ulcers were in place as ordered by the physician for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Finding includes: During an observation on 7/7/25 at 11:40 a.m., CNAs 1 and CNAs 2 were providing care. The resident was rolled to her right side. There was a pressure ulcer observed on the left hip, and superficial open areas on the lower back/sacrum area and right buttock. The right buttock had bloody drainage present. There were no dressings on any of the open areas. CNAs 1 looked in the brief and linens being removed from under the resident and found no dressings. CNAs 1 and CNAs 2 indicated they had not been made aware the dressings were not present by the previous shift. During an interview on 7/7/25 at 11:45 a.m., the Wound Nurse indicated the treatments had been completed by her on 7/3/25. There were physician's orders to change the dressings if soiled or if the dressings came off. During an interview on 7/7/25 at 12:00 p.m., the Director of Nursing indicated…

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 record review and interview, the facility failed to ensure residents received blood sugar monitoring, insulin and hypoglycemic medications as ordered by the Physician for 3 of 3 residents reviewed for diabetes management. (Residents B, C and D) Findings include: 1. Resident B's closed record was reviewed on 6/4/25 at 10:43 a.m. The diagnoses included, but were not limited to, diabetes mellitus. A Quarterly Minimum Data Set (MDS) assessment, dated 4/28/25, indicated the resident received insulin in the past 6 days. A Physician's Order, dated 4/23/25 and discontinued on 5/9/25 at 1:37 p.m., indicated blood sugar levels were to be obtained before meals and at bedtime and the amount of humalog insulin to be administered was dependent on the blood sugar results (sliding scale). The order indicated blood sugar results 0-150: no insulin was to be given, blood sugars 151-200: 2 units were to be given, blood sugars 201-250: 4 units were to be given, blood sugars 251-300: 6 units were to be given, blood sugars 301-350, 8 units were to be given, blood sugars 351-400, 10 units were 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 food was prepared in form to meet individual needs related to not following a recipe for pureed food and not making pureed food the correct consistency. This had the potential to affect all 5 residents who received a pureed diet. (Main Kitchen) Finding includes: On 7/10/24 at 10:29 a.m., [NAME] 1 was observed preparing pureed food. She indicated she was going to puree 5 servings of broccoli. The cook had a recipe titled, Pureed Broccoli. She poured the broccoli with an unknown amount of liquid into the blender. She added 3 tablespoons of a thickening powder to the blender and began to blend. She then added 2 more tablespoons of thickener and blended again. She poured the broccoli out of the blender into a separate container. The cook indicated the puree was finished, the correct consistency, and ready to be served. The pureed broccoli was observed to be watery with no thickened consistency. The Dietary Manager (DM) indicated the puree was too thin and for the cook to add more thickener. The cook then…

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, record review and interview, the facility failed to ensure infection control measures were in place and implemented related to lack of a clothing protector used when sorting soiled laundry, incorrect signage posted for a resident on contact isolation, and not cleaning a shared blood pressure cuff between uses. (Laundry Aide 1, QMA 1, and Resident 23) Findings include: 1. On 7/12/24 at 10:50 a.m., the laundry room was observed with Laundry Aide 1. In the dirty laundry sorting area, there were no aprons or clothing coverings observed hanging. During an interview at that time, the Laundry Aide indicated she wore gloves when sorting the dirty laundry. She did not wear any type of clothing protector and indicated she had never been instructed to do so. The Laundry Policy was received and did not address the above issue. 2. On 7/11/24 at 9:16 a.m., QMA 1 was observed preparing medications for the resident in Room B 5-1. QMA 1 indicated she was going to check the resident's blood pressure prior to administering the medications, but needed the blood pressure cuff,…

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, record review, and interview, the facility failed to ensure residents had physician's orders for a medication, physician's orders for self-administration of medications, and a self-administration of medications assessment completed for 1 of 2 residents reviewed for self-administration of medication. (Resident 4) Finding includes: On 7/8/24 at 11:51 a.m., there was a bottle of fluticasone spray (nasal spray) observed on Resident 4's bedside table. At the time, the resident indicated that she took the nasal spray by herself whenever she felt that she needed it. On 7/10/24 at 11:54 a.m., the bottle of fluticasone spray was still observed on the bedside table. Resident 4's record was reviewed on 7/10/24 at 11:14 a.m. Diagnoses included, but were not limited to, heart failure and adult failure to thrive. The Quarterly MDS (Minimum Data Set) assessment, dated 6/5/24, indicated the resident was cognitively intact for daily decision making. There were no physician's orders for the fluticasone spray. There was no care plan for self-administration of the fluticasone.…

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, record review and interview, the facility failed to notify the family/representative of new orders for medications for 1 of 5 residents reviewed for unnecessary medications. (Resident B) Finding includes: Resident B's record was reviewed on 7/9/24 at 11:18 a.m. Diagnoses included, but were not limited to, schizoaffective disorder, anxiety disorder, dementia with behavioral disturbance, and bipolar disorder without psychotic features. The Quarterly Minimum Data Set (MDS) assessment, dated 6/26/24, indicated the resident was severely cognitively impaired for daily decision making. Medications received while a resident included, but were not limited to, antipsychotics on a routine basis, anti-anxiety medications, and opioids (pain medications). A Nurses' Note, dated 5/23/2024 at 8:11 p.m., indicated the resident complained of right hip pain. A new order was placed for Icy Hot Patch daily to the right hip and off at bedtime. A Nurses' Note, dated 5/29/2024 at 3:58 p.m., indicated the Psychiatric Nurse Practitioner placed a new order for sertraline (an…

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 record review and interview, the facility failed to ensure quarterly care plan meetings were completed and/or family representatives were invited for 3 of 4 residents reviewed for care planning. (Residents D, E and B) Findings include: 1. During an interview on 7/8/24 at 11:05 a.m., Resident D's Power of Attorney (POA)/ family representative indicated she had not been invited to a care plan meeting in a very long time. They used to do phone conferences, but that had not occurred recently. The resident's record was reviewed on 7/9/24 at 11:54 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided weakness) and hemiparesis (one sided paralysis) following a cerebral vascular accident, dysphagia, and contracture of the right hand. The Quarterly Minimum Data Set (MDS) assessment, dated 5/28/24, indicated the resident had severe cognitive impairment, required set up assistance for meals, and extensive 2+ staff assistance for bed mobility. There was no documentation a care plan meeting 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.

Based on interview, observation, and record review, the facility failed to ensure residents received the necessary care for activities of daily living (ADLs) related to the lack of documentation of incontinence care and residents with long, dirty fingernails and toenails for 3 of 11 residents reviewed for ADL care. (Residents 10, 4 and C) Findings include: 1. On 7/8/24 at 11:30 a.m., Resident 10 was interviewed. The resident indicated the staff never check his brief to see if he needed to be changed. Record review for Resident 10 was completed on 7/9/24 at 1:53 p.m. Diagnoses included, but were not limited to hypertension, anxiety, depression, bipolar, and psychotic disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 4/12/24, indicated the resident was cognitively intact. The resident required a substantial assistance for bed mobility and was dependent for transfers. The resident was always incontinent of bladder. A Care Plan, dated 5/17/23, indicated the resident experienced bladder incontinence. An intervention included to check and change with routine care rounds and…

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

Based on observation, record review, and interview, the facility failed to ensure residents received the necessary care and treatment, related to administering a blood pressure medication out of the prescribed parameters, the lack of assessment and a treatment order for a resident with a bandage, and a resident not wearing preventative heel protectors as ordered, for 1 of 5 residents reviewed for unnecessary medications (Resident 28) and 2 of 4 residents reviewed for non-pressure skin conditions. (Residents 39 and C) Findings include: 1. Record review for Resident 28 was completed on 7/11/24 at 12:22 p.m. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, hypertension, and orthostatic hypotension. The admission Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the resident was cognitively intact. The July 2024 Physician's Order Summary indicated an order for midodrine hcl (treats low blood pressure) 2.5 mg (milligrams) twice a day for orthostatic hypotension. Hold the medication if the systolic blood pressure (SBP) (top reading of a blood…

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 record review and interview, the facility failed to ensure residents with impaired hearing received the necessary services for 1 of 1 resident reviewed for hearing. (Resident C) Finding includes: During an interview on 7/8/24 at 9:31 a.m., Resident C indicated he was in need of hearing aids. He was observed to be hard of hearing, was yelling out, and was reading lips while in conversation. Resident C's record was reviewed on 7/11/24 at 9:28 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis affecting the right dominant side and vascular dementia. The Annual Minimum Data Set (MDS) assessment, dated 5/3/24, indicated the resident was cognitively intact for daily decision making and had adequate hearing. There were no care plans related to hearing loss. During an interview on 7/11/24 at 1:54 p.m., the Social Service Director indicated she was never informed that the resident wanted to see an audiologist, however he was hard of hearing. She did not provide any further information or prior visits from an audiologist. During an interview on 7/11/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident received the necessary treatment to prevent decreased range of motion, related to a splint not in place as recommended for 1 of 3 residents reviewed for range of motion. (Resident D) Finding includes: On 7/8/24 at 11:07 a.m., Resident D was observed lying in bed. Her right hand was contracted (fixed tightening of muscle, tendon, ligament or skin) and there was a hand splint hanging on the wall next to her bed. The resident was observed again on 7/9/24 at 11:26 a.m., 7/10/24 at 8:49 a.m., and 7/11/24 at 8:47 a.m. lying in bed without the hand splint in place. The resident's record was reviewed on 7/9/24 at 11:54 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided weakness) and hemiparesis (one sided paralysis) following a cerebral vascular accident, dysphagia, and contracture of the right hand. The Quarterly Minimum Data Set assessment, dated 5/28/24, indicated the resident had severe cognitive…

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, record review, and interview, the facility failed to ensure a resident with dysphagia (difficulty swallowing) received adaptive equipment as ordered during meals for 1 of 2 residents reviewed for nutrition. (Resident D) Finding includes: On 7/10/24 at 8:49 a.m., Resident D was observed in bed eating breakfast. There was Styrofoam cup with water and a straw, a cup of juice, and a cup of coffee. There was no 2 handled mug present on the breakfast tray. At 10:15 a.m., the resident was observed again in bed. The cup with the straw and beverage cups had been removed and there was a 2 handled mug on her table. On 7/12/24 at 9:20 a.m., CNA 1 was observed removing the resident's breakfast tray from her table. There was a cup of juice with a straw and a cup of coffee. There was no 2 handled mug on the tray. The CNA indicated she had not put the straw in the cup and it must have come from the kitchen. There was a tray ticket on her tray that indicated no straws and to use a 2 handled mug. The resident's record was reviewed on 7/9/24 at 11:54 a.m. Diagnoses included, but…

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, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration for 1 of 1 resident reviewed for respiratory care. (Resident 1) Finding includes: On 7/8/24 at 9:08 a.m. Resident 1 was observed lying in bed with her eyes closed. She had an oxygen concentrator at her bedside that was on and set at 2 liters (L). A nasal cannula was attached to the concentrator and was laying on the floor beside the bed. On 7/9/24 at 11:37 a.m. Resident 1 was observed lying in bed with her eyes closed. She had the nasal cannula in place and the oxygen was running at 2 L. On 7/10/24 at 2:52 p.m. Resident 1 was observed lying in bed with her eyes closed. The oxygen concentrator was on and set at 2 L. The nasal cannula was hanging on the tube feeding pole beside the resident's bed. On 7/11/24 at 8:35 a.m. Resident 1 was observed lying in bed with her eyes closed. She had the nasal cannula in place and the oxygen was running at 2 L. Record review for Resident 1 was completed on 7/10/24 at 9:07 a.m. 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 record review and interview, the facility failed to ensure pain medications were available and administered to a resident per the physician's orders for 1 of 2 residents reviewed for pain. (Resident C) Finding includes: During an interview on 7/8/24 at 9:37 a.m., Resident C indicated that he received scheduled pain medications, however he often missed doses due to the medications not being available in the facility. Resident C's record was reviewed on 7/11/24 at 9:28 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis affecting the right dominant side and vascular dementia. The Annual Minimum Data Set (MDS) assessment, dated 5/3/24, indicated the resident was cognitively intact for daily decision making. He received opioid pain medications. A Care Plan, dated 7/4/24, indicated the resident was at risk for complaints of pain. Interventions included, but were not limited to, administer analgesia as per orders. A Physician's Order, dated 5/1/24, indicated hydrocodone-acetaminophen 10-325 milligrams (mg) tablet, 1 tablet by mouth every 6 hours. The June…

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 correct Personal Protective Equipment (PPE) was used by a staff members (CNA 1), when providing care to a resident who was in Enhanced Barrier Precautions for 1 of 3 residents observed who were in EBP. (Resident D) This had the potential to affect 34 residents who resided on 1 of 2 Units. (A-Unit) Finding includes: During an observation on 5/30/24 at 11:06 a.m., there was a sign on the wall outside of Resident D's door that indicated the resident was on Enhanced Barrier Precautions. There was no PPE located outside or inside of the room. During an observation on 5/30/24 at 11:32 a.m., CNA 1 entered the room, donned gloves and started to initiate incontinence care and was stopped. CNA 1 removed the gloves and stepped into the hallway where the EBP sign was reviewed. CNA 1 indicated she was unsure what EBP was and indicated if the resident was on isolation, there was usually a cart with PPE outside the door. The Administrator was then interviewed and indicated more containers for PPE were ordered and PPE…

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, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) related to the timeliness of incontinence care, for 2 of 3 residents reviewed for ADLs. (Residents B and C) Findings include: 1. During a random observation on 8/8/24 at 4:15 a.m., CNA 1 was observed walking into Resident B's room. At that time, she indicated she was going to check him for incontinence and provide care if needed. There was a foul odor of bowel movement in the room, and the resident was observed in bed lying on the right side. The resident's incontinent brief was noted to be on the floor. The CNA removed the top sheet and observed a large amount of bowel movement on the top sheet, bottom sheet, on the incontinence pad and on the resident's buttocks. The CNA started to clean the resident with incontinence wipes and, as she was doing so, the bowel movement was sticking to the resident's buttocks and was hard to remove. There was also a large amount of food crumbs observed in the bed. During an interview at 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 record review and interview, the facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect 64 of 64 residents who resided in the facility. Finding includes. Review of the nursing staffing schedules for November 2023 on 12/6/23 at 2 p.m., indicated there was no RN in the facility for eight consecutive hours on November 11, 2023. During an interview on 12/7/23 at 8:57 a.m., the Director of Nursing acknowledged the schedule for 11/11/23 indicated the RN who was scheduled had called off and there was no other RN in the building for eight consecutive hours. This citation related to Complaints IN00419693, IN00422944, and IN00423001. 3.1 -17(b)(3)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the residents' environment was sanitary and comfortable, related to cob webs, dirt and debris on the floor, liquid feeding dried on IV/feeding pump poles, a feeding pump, and floors, cable and outlet covers loose or off, a soiled over the bed table, an over the bed table with a gouge, a cracked floor mat, a wedge pillow stored on the floor, and an accumulation of dust on a bathroom fan, for rooms on 2 of 2 Units. (B-Unit and A-Unit) Findings include: During an Environmental Tour, on 12/7/23 from 10 a.m. to 10:23 a.m., with Employee 1 and the Regional [NAME] President of Operations, the following was observed: 1. B-Unit a. room [ROOM NUMBER], where one resident resided, had cobwebs on the floor under the closet door and under the desk and debris on the floor near the base boards. b. room [ROOM NUMBER] had dried liquid feeding on the base of the IV pole. There was an IV pump on the pole. c. room [ROOM NUMBER] was observed empty 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, record review, and interview, the facility failed to ensure a resident who was being transferred in a bus to an appointment was secured appropriately in the bus to prevent the wheelchair from tipping over and also failed to ensure a Physician's Order and Care Planned intervention was in place to prevent falls, related to anti-roll back device was not located on a wheelchair for 2 of 3 residents reviewed for accidents. (Residents K and G) Findings include: 1. Resident K's record was reviewed on 12/5/23 at 1 p.m. The diagnoses included, but were not limited to, multiple sclerosis and convulsions. A Quarterly Minimum Data Set (MDS) assessment, dated 9/5/23, indicated a moderately impaired cognitive status, extensive assistance of two for transfers, and supervision for locomotion. A Care Plan, dated 5/25/23, indicated a risk for falls and a wheelchair was used for locomotion. The interventions included, anti-roll back device for the wheelchair and a non-slide pad (dycem) for the wheelchair seat. A Nurse's Note, dated 11/28/23 at 1:15 p.m., indicated the a call from…

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

Based on observation, record review, and interview, the facility failed to ensure there was sufficient dietary staff available to effectively serve meals in a timely manner. This had the potential to affect 65 residents who received meals from the kitchen. (Main Kitchen) Finding includes: On 7/24/23 at 9:30 a.m., Resident 34, who resided on the A Unit, was observed lying in bed yelling out that she was hungry. Interview with QMA 1 at that time indicated the breakfast trays had not been brought to the unit yet and the resident always says she's hungry. The QMA didn't indicate he would check on the room trays or offer to get the resident something to eat. A breakfast room tray cart was observed to arrive to the A Unit at 10:00 a.m. Review on 7/28/23 at 10:00 a.m. of the Resident Council Follow-Up, indicated that on 7/3/23, it was brought to the facility's attention the residents had a concern that meals were very late on the weekends. The Dietary Manager (DM) response, dated 7/7/23, indicated, Apologize for tardiness of meals on weekends! Often have call-offs and do our very best to…

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

Based on observation and interview, the facility failed to keep the residents' environment clean and in good repair related to dirty floors, damaged walls, peeling non-skin strips, a running toilet, and broken furniture on 2 of 2 units. (The A and B Units) Findings include: During the environmental tour, on 7/28/23 at 9:20 a.m., with the Maintenance Director and the Administrator, the following was observed: 1. A Unit a. The A unit common area carpet was dirty, there was debris under the chairs and the end table was missing the drawer. 31 residents resided on the A Unit. b. Room A05: the bathroom floor was dirty and the non-skid strips were peeling off the floor. Two residents resided in the room. c. Room A07: there was a build up of dirt on the bathroom floor. Two residents resided in the room. d. Room A17: there was a buildup of dirt around the bathroom baseboards. Two residents resided in the room. e. Room A19: the non-skid strips in the bathroom were peeling off the floor and the call light cord was only about three inches long. One resident resided in that room. 2. B Unit- 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 observation and interview, the facility failed to ensure residents had access to their personal funds at all times for 1 of 2 residents reviewed for personal funds. (Resident 67) Finding includes: On 7/24/23 at 8:40 a.m., the Resident Trust Banking Hours were observed posted at the front desk. The hours were Monday-Friday 8:00 a.m. to 4:00 p.m. and Saturday-Sunday 9:00 a.m.-5:00 p.m. Interview with Resident 67, on 7/24/23 at 10:22 a.m., indicated she was not able to get money from her personal funds account on the weekends. Interview with the Business Office Manager, on 7/28/23 at 2:47 p.m., indicated the receptionist kept resident funds in a lock box and she would give them money as requested. If the receptionist wasn't there, no one else had access to the lockbox or kept money on hand for the residents. 3.1-6(f)(1)

Based on observation, record review, and interview, the facility failed to develop and implement comprehensive, resident-centered Care Plans related to activities, antidepressant medications, diabetes and anticoagulant medications for 2 of 17 resident Care Plans reviewed. (Residents 44 and 34) Findings include: 1. On 7/24/23 at 10:00 a.m., 7/25/23 at 11:48, 7/26/23 at 8:38, 10:00 a.m., and 12:35 p.m., Resident 44 was observed lying in bed with the television on. The resident indicated she liked to get out of bed for an hour sometimes, but she couldn't remember the last time she had been out of bed. The resident's record was reviewed on 7/25/23 at 11:10 a.m. Diagnoses included, but were not limited to, Parkinson's disease, weakness and neuropathy. The Quarterly Minimum Data Set assessment, dated 7/1/23, indicated a cognitive assessment could not be completed, and the resident required extensive one person assistance for transfers and toileting and two person assistance for bed mobility. The Quarterly Activities Evaluation, dated 7/5/23, indicated it was somewhat important 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 observation, record review, and interview, the facility failed to ensure an ongoing activity program was implemented for dependent residents for 3 of 4 residents reviewed for activities. (Residents 44, 34 and 40) Findings include: 1. On 7/24/23 at 10:00 a.m., 7/25/23 at 11:48, 7/26/23 at 8:38, 10:00 a.m., and 12:35 p.m., Resident 44 was observed lying in bed with the television on. The resident indicated she liked to get out of bed for an hour sometimes, but she couldn't remember the last time she had been out of bed. The resident's record was reviewed on 7/25/23 at 11:10 a.m. Diagnoses included, but were not limited to, Parkinson's disease, weakness and neuropathy. The Quarterly Minimum Data Set assessment, dated 7/1/23, indicated a cognitive assessment could not be completed, and the resident required extensive one person assistance for transfers and toileting and two person assistance for bed mobility. The Quarterly Activities Evaluation, dated 7/5/23, indicated it was somewhat important to the resident to do things in groups of people, listen to music she liked, do…

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, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of a resident with a possible change in condition for 1 of 1 residents reviewed for change in condition, monitoring and assessment of skin discolorations for 1 of 2 residents reviewed for non-pressure related skin conditions, and an improper length of a bed for 1 of 1 residents reviewed for positioning. (Residents 63, 43 and 13) Findings include: 1. On 7/26/23 at 11:50 a.m., RN 2 was observed passing medication to Resident 63. The resident was seated in his wheelchair. His head was tipped forward toward his chest and his eyes were closed. A family member was present and indicated she thought he was getting worse. She indicated his left side seemed weaker, he was less alert than usual and complained about pain in his stomach. The RN indicated she would get him back to bed after lunch. She indicated she wasn't familiar with the resident and would have to look in his chart. She then exited the room. 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 observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing, related to the lack of a timely treatment put into place for 1 of 4 residents reviewed for pressure ulcers. (Resident 40) Finding includes: On 7/26/23 at 9:49 a.m., Resident 40 was observed receiving wound care from the Wound Nurse. The resident had an open area observed to her right ankle. The area was approximately the size of a half dollar coin. The area was red with slough (dead skin tissue) observed to the bed of the wound. Record review for Resident 40 was completed on 7/26/23 at 9:20 a.m. Diagnoses included, but were not limited to, stroke, aphasia (loss of ability to understand or express speech), dementia, depression, and hemiplegia (paralysis of one side of the body). The Quarterly Minimum Data Set (MDS) assessment, dated 6/3/23, indicated the resident was moderately cognitively impaired. The resident required an extensive 1 person assist with bed mobility. The resident did not have any 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.

Based on observation, record review, and interview, the facility failed to identify or act on an irregularity in a resident's medication regimen related to an unnamed medication being administered for 1 of 5 residents reviewed during medication pass. (Resident 1) Finding includes: On 7/27/23 at 9:00 a.m., LPN 1 was observed giving Resident 1 medication during medication pass observation. The July 2023 Medication Administration Record (MAR) included a medication called drug to be applied to the left side of the resident's neck twice daily. The LPN indicated she did not know what that medication was. She looked through the medication and treatment carts and was unable to locate a topical medication for the resident. She then looked at the Physician Orders, and indicated the medication was called drug. She indicated she would have to call the Physician to clarify the order. A Physician's Order, dated 5/12/23, indicated to apply drug twice daily to the left side of neck for redness, itching and swelling. The July 2023 MAR indicated the medication drug was administered 44 times 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.