Addison Heights Health And Rehabilitation Center

Based on record review, review of the facility's investigation, review of Self-Reported Incident (SRI) #267064, staff interview, police report review, and facility policy review, the facility failed to provide adequate supervision which resulted in an incident of sexual abuse. This affected one (#36) of five residents reviewed for abuse. The facility census was 68.1. Review of the medical record for Resident #36 revealed an admission date of 06/27/25 with diagnoses of Alzheimer's disease, cerebral infarction, depression, anxiety, and cerebrovascular disease.Review of the comprehensive, significant change Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #36 had severely impaired cognition, used a wheelchair for mobility and was dependent on staff for all activities of daily life.Review of a nursing progress note dated 11/01/25 at 10:57 P.M., and written by the Director of Nursing, revealed Resident #36 was in her wheelchair in the lounge and another resident (Resident #73) had his hand in her brief. The residents were immediately separated and placed on 15-minute…

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, staff interview, review of Self-Reported Incident #267064, and review of the facility policy, the facility failed to ensure an allegation of sexual abuse was reported timely to the State Agency. This affected one (Resident #36) of five residents reviewed for abuse. The facility census was 68.Review of the medical record for Resident #36 revealed an admission date of 06/27/25 with diagnoses of Alzheimer's disease, cerebral infarction, depression, anxiety, and cerebrovascular disease.Review of the comprehensive, significant change Minimum Data Set (MDS) assessment, dated 12/10/25, revealed Resident #36 had severely impaired cognition, used a wheelchair for mobility and was dependent on staff for all activities of daily life.Review of a nursing progress note dated 11/01/25 at 10:57 P.M., and written by the Director of Nursing, revealed Resident #36 was in her wheelchair in the lounge and another resident (Resident #73) had his hand in her brief. The residents were immediately separated and placed on 15-minute checks.Review of the facility's Self-Reported…

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, observation, staff interview, and facility policy review, the facility failed to ensure medications were given per physician order. This affected two (#85 and #55) of seven residents reviewed for medication administration. The facility census was 68. Findings Include:1. Review of the medical record for Former Resident, Resident #85 revealed an admission date of 10/10/25. Resident #85 discharged home on [DATE]. Diagnoses included a fractured neck of right femur, osteoarthritis, anxiety, schizoaffective disorder, and venous thrombosis. Review of the 5-day Minimum Data Set (MDS) assessment, dated 10/17/25, revealed Resident #85 had impaired cognition.Review of the physician orders initiated 10/10/25 revealed Resident #85 should have received Senna (laxative) oral tablet, 8.6 milligrams (mg), two tablets by mouth once daily for constipation, Cefuroxime Axetil (an antibiotic) oral tablet 500 mg, one tablet twice daily for infection for five days; Eliquis (anticoagulant) oral tablet 5 mg, one…

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

Based on observation, staff interview, record review, and policy review, the facility failed to ensure food items were labeled with open dates and failed to ensure staff were knowledgeable regarding identifying expiration dates of packaged foods. This affected one (#16) resident identified to be on thickened liquids. The facility census was 68.Findings Include: Review of the medical record for Resident #16 revealed an admission date of 03/01/21 with diagnoses of hemiplegia/hemiparesis, cerebral infarction, and chronic obstructive pulmonary disease. Review of the 5-day Minimum Data Set (MDS) assessment, dated 11/23/25, revealed Resident #16 had impaired cognition. Review of a physician order dated 11/19/25 and discontinued 12/02/25 revealed Resident #16 was on nectar thick liquids.Review of a current physician order dated 12/02/25 revealed Resident #16 was on nectar thickened liquids.Observations of food storage on 12/01/25 beginning at 3:20 P.M. and concurrent interview with Dietary Manager (DM) #395, revealed a reach-in cooler with four 46-ounce cartons of nectar thickened…

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 mattresses and bedframes were compatible. This affected one (#58) of three residents reviewed for mattress and bed frame compatibility. The facility census was 68. Findings Include:Review of the medical record for Resident #58 revealed an admission date of 05/02/25 with diagnoses of morbid obesity, muscle weakness, and Type II Diabetes Mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/25, revealed Resident #58 had intact cognition and was able to roll to the left and right with supervision and/or touching assistance.Review of the current physician order dated 05/07/25 revealed Resident #58 required a low air loss mattress at all times. Observation and interview on 12/01/25 at 1:50 P.M. with Resident #58 revealed a grab bar was on the left side of his bed, but no grab bar was on the right side of his bed. Resident #58 stated the mattress was too big for the frame. Observation and interview on 12/01/25 at 1:56 P.M. with Maintenance Director (MD) #351 confirmed Resident #58's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of Self-Reported Incidents, review of witness statements, and review of facility policy, the facility failed to immediately report an allegation of staff to resident abuse to the State Survey Agency. This affected one (#27) of three residents reviewed for abuse. The facility census was 63. Findings include:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included sepsis, other seizures, bipolar disorder, dysphagia-oropharyngeal phase, epilepsy, muscle weakness, other disorders of psychological development, and major depressive disorder. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #27 was rarely or never understood by staff. Review of the plan of care dated 08/07/25 revealed Resident #27 was at risk for falls related to confusion, and unawareness of safety needs. Interventions included providing the resident with activities that were appropriate for the resident…

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 staff interview, and review of facility staffing documentation, the facility failed to ensure a Registered Nurse was scheduled eight consecutive hours when the facility exceeded a census of 60 residents. This affected all 60 residents residing in the facility. Review of facility staffing documentation and related schedules between 09/01/25 and 09/07/25. Facility census was 61 current residents on 09/04/25, 09/05/25, 09/06/25. The facility Director of Nursing was listed as the only Registered Nurse in the facility. On 09/11/25 at 1:07 P.M. interview with Scheduling Coordinator (SC) #466 during a review of facility schedules between 09/01/25 and 09/07/25 verified no additional Registered Nurse was scheduled in the facility on 09/04/25, 09/05/25, 09/06/25. SC #466 also confirmed the facility exceeded a resident census of 60 on each of the three days. This deficiency represents non-compliance investigated under Complaint Number 2608577.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of manufactures guidelines, review of pharmacy policy, and review of facility policy, the facility failed to store medications that require refrigeration. This affected Resident #13. The facility failed to ensure the freezer, located inside of the medication-storage refrigerator, was properly maintained. This affected eight residents (#10, #13, #33, #34, #37, #42, #60, and #68) that were identified by the facility as utilizing medications that required refrigeration. The facility also failed to ensure the medication-storage refrigerator maintained the correct temperature parameters to safely store medications that require refrigeration. This affected eight residents (#10, #13, #33, #34, #37, #42, #60, and #68) that were identified by the facility as utilizing medications that required refrigeration. The facility also failed to ensure that multi-use vials of medication were labeled properly when opened. This had the potential to affect all residents in the facility.…

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, staff interviews, resident interviews, and schedule reviews the facility failed to ensure adequate kitchen staff were available to provide timely meal service. This affected all residents. The facility census was 60.Observation of the kitchen staff on 09/08/25 at 8:00 A.M. revealed only Dietary Manager #504 was working in the kitchen and was preparing the breakfast meal.Review of the dietary staffing schedule dated 09/08/25 revealed one cook was scheduled from 6:00 A.M. to 2:00 P.M., and a dietary aide from 7:00 A.M. to 3:00 P.M. and a second aide from 10:00 A.M. to 8:00 P.M. There were two open shifts from 4:00 P.M. to 7:00 P.M. and 7:00 A.M. to 10:00 A.M.Interview with Dietary Manager #504 on 09/08/25 at 8:00 A.M. revealed two additional staff were scheduled, but failed to come into work.Observation at 12:45 P.M. revealed Resident #26 was in the main lobby asking staff where lunch was because she was hungry.Observation on 09/08/25 revealed lunch service was not provided until 1:00 P.M. to 1:42 P.M. Interview with Residents #22, #26, and #30 revealed lunch was…

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

Based on observation, staff interview, and policy review the facility failed to dispose of expired foods and store foods properly. This had the ability to affect all residents. The facility census was 60.Kitchen observation on 09/08/25 at 7:57 A.M. revealed several foods were found expired in the walk in refrigerator. A plastic container of pears was dated 08/30/25 and marked to be used by 09/03/25. A large plastic container of jelly was dated 08/04/25 and use by date was 09/04/25. A plastic container was dated 09/07/25 and use by date was 09/07/25. Further observation revealed two five pound rolls of ground beef were sitting on a tray and had a red liquid substance on the tray. The meat failed to be labeled with dates.Observation of the walk-in freezer on 09/08/25 at 8:05 A.M. revealed a plastic bag of frozen chicken patties were left open to air. Observation of the dry storage area on 09/08/25 at 8:08 A.M. revealed a plastic bin sitting on the floor with bread crumbs inside. The lid failed to be attached properly and was allowing the crumbs to be open to air.Interview with Dietary…

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 staff interview, the facility failed to implement and monitor an effective water management program to minimize the risk for Legionella growth in the facilities building. This had the potential to affect all residents. The facility census was 60. Review of the facilities policy titled Legionella Infection Control Protocol, undated, revealed the facility will flush toilets and run sinks in resident's rooms daily to flush any standing water. The facilities protocol does not address flushing water in any other areas or a way to track and monitor areas that have been flushed. Interview on 09/09/25 at 12:11 P.M. with Director of Maintenance #458 revealed that maintenance runs water in all rooms and that water is tested with an instant read tester for Legionella randomly and a sample is sent out yearly for testing. Maintenance Director did not know if tracking sheets for the flushes or the yearly test results were available due to only working there since June. Interview on 09/09/25 at 3:13 P.M. with Director of Maintenance #458 revealed a document titled…

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, resident interview, staff interview, review of medical record, and review of facility policy, the facility failed to ensure there was an adequate supply of linens to meet resident needs. This affected Resident #10. The facility also failed to ensure shower chairs were in good repair and functional in the 100-hall shower room. This affected 28 residents (#5, #6, #8, #10, #13, #17, #18, #20, #24, #25, #26, #28, #32, #33, #34, #38, #39, #41, #43, #44, #45, #46, #49, #52, #56, #58, and #63) identified by the facility as using this shower room and residing in the 100 and 200 halls. The facility failed to ensure a clean and homelike environment in resident rooms. This affected two residents (#10 and #17). The facility failed to ensure resident window shades were in functional working order. This affected two residents (#22 and #51). The facility failed to ensure baseboard heater covers were in place and intact in resident rooms. This affected Resident #20. The facility failed to ensure the walls…

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, resident interview, staff interview, review of medical record, and review of facility policy, the facility failed to provide care and services in the area of personal hygiene. This affected four residents (#8, #20, #31, and #44) of five residents reviewed for activities of daily living. The facility census was 60.1. Review of the medical record for Resident #31 revealed an admission date of 06/27/25 with diagnoses of thyroid disorder, cerebrovascular accident (CVA), non-Alzheimer ' s dementia, and anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderate cognitive impairment and a requirement of substantial assistance with showering or bathing. Observation on 09/09/25 at 9:21 A.M. revealed Resident #31 sitting in a chair in the common area on the memory care unit with greasy unkept hair and approximately three quarter to one inch hair cluster growth on chin. Interview on 09/09/25 at 12:22 P.M. with Unit Manager #463 confirmed Resident…

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, staff interview, and facility pest control documentation, the facility failed to ensure effective insect control was implemented. This affected 10 of 16 residents (#10, #17, #18, #20, #38, #44, #23, #45, #22, #51) reviewed for physical environmental conditions in a facility census of 60. 1.) Observation of Resident #38 on 09/09/25 at 10:36 A.M. revealed the resident was in bed with multiple black flying insects in room and landing on various surfaces. 2.) Observation of Resident #20 on 09/09/25 at 10:50 A.M. revealed black flying insects were observed in the room, landing on resident and bedside beverages sitting on the over bed table. Resident #20 stated insects were visible for an undescribed time and at times landed on food. 3.) Observation of Resident #44 on 09/10/25 at 12:01 P.M. revealed the resident was seated in room at the side of the bed. Black flying insects were noted landing on personal property and beverages. Resident #44 was observed swatting at the pest. On 09/09/25 at 1:34…

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, resident interview, and staff interview the facility failed to properly complete the Minimum Data Set (MDS). This affected one resident (#30) reviewed for vision. The facility census was 60.Review of Resident #30's medical record revealed an admission date of 02/03/25. Diagnoses included acute kidney failure, altered mental status, and malnutrition. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had an intact cognition. His vision was marked as adequate and no corrective lenses were required. Review of Resident #30's most recent care plan revealed the resident received optical services, but the record was absent to vision loss. Review of Resident #30's physician note dated 03/24/25 revealed previous to entering the facility he began loosing his vision and became nearly blind. Review of Resident #30's outside eye exam report dated 04/09/25 revealed the resident had other eye problems and required a referral for cataract surgery. The resident had dense…

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 medical record review, staff interview and review of facility policy the facility failed to ensure the baseline care plan was individualized to meet resident needs. This affected one (#08) of one resident revealed for base line care plans. The facility census was 60. Review of the medical record for Resident #08 revealed an admission date of 07/02/25 with diagnoses of acute cystitis, cerebral infarction, heartburn, anorexia, personal history of transient ischemic attack (TIA), nicotine dependence, hypomagnesemia, other specified health status, major depressive disorder, adult failure to thrive, altered mental status (AMS), Alzheimer's disease, other acquired deformity of head, and unspecified protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) assessment for Resident #08 revealed a Brief Interview of Mental Status (BIMS) score of 06, indicating Resident #08 was severely cognitively impaired. Further review of the MDS assessment for Resident #08 revealed she required substantial or maximal assistance with all Activities of Daily Living (ADLs). On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and resident interviews, the facility failed to ensure venous ulcer preventions were in place. This deficient practice affected one (#45) of one residents reviewed for venous ulcers. The facility census was 60.Review of Resident #45's medical record revealed an admission date of 05/02/25. Diagnoses included local infection of the skin and subcutaneous tissue, chronic venous hypertension with ulcer of the left and right lower extremity, non-pressure chronic ulcer of the left foot and right lower leg with fat layer exposed, pressure-induced deep tissue damage of the right buttock, pressure-induced deep tissue damage of the right sacral region, pressure-induced deep tissue damage of the left buttock, hypertension, and muscle wasting. Review of Resident #45's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #45 was always incontinent of bowel and frequently incontinent of urine, there was a risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, review of facility medical record, and review of facility policy, the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing. This affected two resident (#10 and #45) of two residents reviewed for pressure. The facility census was 60. 1.) Review of the medical record for Resident #10 revealed an admission date of 07/11/25 with diagnoses of pressure ulcer of sacral region stage four, type two diabetes mellitus (DM2), long-term (current) use of insulin, cutaneous abscess of right lower leg (RLL), acute embolism and thrombosis of left femoral vein, cutaneous abscess of right foot, encounter for other specified surgical aftercare, retention of urine, hypotension (HOTN), hypertension (HTN), hyperlipemia, obstructive sleep apnea (OSA), major depressive disorder, respiratory disorders in disease classified elsewhere, anxiety disorder, atrial fibrillation (a. fib), and morbid obesity due to excess…

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, medical record review, staff interview, and facility policy, the facility failed to ensure fall prevention devices were implemented as indicated. This affected two of two residents (#38, #44) reviewed for fall prevention interventions in a facility census of 60. 1.Resident #38 admitted to the facility on [DATE] with the diagnosis including, bipolar disorder, dysphagia, epilepsy, disorder of psychological development, major depression, and acute and chronic respiratory failure with hypoxia. According to the most recent minimum data set assessment dated [DATE] assessed Resident #38 with severely impaired cognition, exhibited physical and other behavioral symptoms, required substantial to maximal assistance with activities of daily living, incontinent of bowel and bladder, received mechanically altered diet, at risk for pressure ulcer development with no current skin breakdown, received antibiotic, antidepressant, antianxiety and anticonvulsant medications. On 08/07/25 a nursing plan of care…

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, medical record review, staff interview, and facility policy the facility failed to provide tracheostomy care and maintenance as ordered by the physician. This affected one of one residents (#6) reviewed for tracheostomy care in a facility census of 60. Resident #6 admitted to the facility on [DATE] with the diagnosis including, chronic respiratory failure with hypoxia, tracheostomy, acute kidney failure, atrial fibrillation, type 2 diabetes mellitus, hypertension, and anxiety disorder. According to the most current minimum data set assessment dated [DATE] assessed Resident #6 with intact cognition, no listed behaviors, dependent on staff for the completion of activities of daily living, received oxygen and tracheostomy treatments. Review of physician orders dated 01/09/22 noted tracheostomy (trach) skin around stoma site and under ties to be assessed during trach care every shift. Notify physician if redness, irritation, drainage, alteration to skin integrity. In addition, trach care is 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, staff interview, and review of a facility policy, the facility failed to provide a clean, well-maintained, and homelike environment. This affected 10 (#7, #9, #20, #30, #31, #32, #33, #34, #35, and #50) of 63 residents residing in the facility. The facility census was 63. Findings include: 1. Observation on 06/30/25 at 6:45 A.M. of the room occupied by Resident #50 revealed spider webs in the right corner of the window sill between the blind and window, the cover for the radiant heater was not properly attached on the left side and was laying on the floor, the window sill had four pieces of missing laminate and two additional areas of missing laminate covered with an unknown substance in an attempt to repair them. The window sill also contained an approximately six inch long crack extending from front to back, an area of missing paint on the wall above the bed approximately two inches long and three inches wide. There was an approximately six inches long and 10 inches wide section of wall covered with plaster and not painted above the resident's bed to the left…

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 medical record review, review of care conference documentation, staff interview, and review of a facility policy, the facility failed to ensure care conferences were held for residents as required. This affected one (#1) of three residents reviewed for timely care planning conferences. The facility census was 63. Findings include: Review of the medical record for Resident #1 revealed an admission date of 01/16/25 with diagnoses including encephalitis, dementia, abnormal findings of the lung field, latent tuberculosis, hypokalemia, and restlessness and agitation. Further review revealed Resident #1 had a discharge date of 06/05/25. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 03, indicating Resident #1 was cognitively impaired. Further review of the MDS assessment for Resident #1 revealed she required assistance with all functional abilities. Review of the facility supplied care conference documentation for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of a facility clinical protocol, the facility failed to ensure interventions to prevent skin breakdown were implemented as ordered by the physician. This affected one (#3) of three residents reviewed for skin breakdown and pressure relieving interventions in a facility census of 63. Findings include: Review of the medical record for Resident #3 revealed the resident admitted to the facility on [DATE] with diagnoses including, multiple sclerosis, coronary artery disease, hypertension, major depressive disorder, metabolic encephalopathy, muscle weakness, and dementia. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was assessed with moderately impaired cognition, dependent on staff for the completion of activities of daily living including transfer and bed mobility, noted as incontinent of bowel and bladder, and was at risk for pressure ulcer development with no current skin breakdown. Review 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, medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure residents were provided a comfortable and homelike environment. This affected three (#18, #27, #49) of six resident rooms observed and had the potential to affected all 26 residents (#39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, and #64) who resided in the memory care unit in a facility census of 64. Findings Include: 1. Observation on 04/30/25 at 6:50 A.M. revealed Resident #53 in the common area of the memory care (MC) unit seated in a wheelchair wearing a heavy winter coat with the hood pulled over her head. Concurrent observation revealed Resident #41 seated in a wheelchair wrapped in a blanket. Interview on 04/30/25 at 7:00 A.M. with Resident #53 verified she was wearing a coat due to the cold air temperature of the MC unit. Resident #53 indicated it was always cold on the MC unit. Interview 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, staff interview, review of Safety Data Sheets (SDS) documents, review of product labels, and policy review, the facility failed to ensure chemicals were stored in a safe and secure manner. This had the potential to affect four (#17, #21, #23, and #27) of four residents identified by the facility as being cognitively impaired and independently mobile who resided outside of the memory care (MC) unit. The facility census was 64. Findings Include: Observation on 04/29/25 at 12:53 P.M. of the linen cart located by Resident #12 and Resident #22's room revealed one canister of Sani-Cloth germicidal disposable wipes with a purple colored top and one canister of Sani-Cloth bleach germicidal disposable wipes with an orange colored top. Further observation revealed both canisters were open and accessible to residents. Review of the product label for the Sani-Cloth germicidal disposable wipes revealed they are not skin or baby wipes and to keep out of reach of children. The product label indicated when using the product, wear disposable protective gloves, protective gowns,…

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, resident interview, resident representative interview, staff interview and review of facility policy, the facility failed to ensure the facility was free from pervasive odors. This had the potential to affect all residents in the facility except for 16 (#12, #13, #15, #16, #18, #19, #24, #26, #31, #37, #38, #41, #46, #57, #58, #75) residents identified by the facility as residing on the secured memory care unit. The facility census was 68. Findings include: Observation on 02/19/25 at 9:38 A.M., upon entering the facility, revealed the facility reception area was malodorous. Observation on 02/19/25 at 10:30 A.M. revealed the resident halls, excluding the memory care unit, had a pungent odor. A strong foul odor was noted near the nurses station, with no residents present. Interview on 02/19/25 at 10:35 A.M. with Certified Nursing Assistant (CNA) #148 verified the pungent odor and stated the odor primarily came from the hall where there were residents who declined assistance with care. CNA #148 stated the hall always smelled foul. CNA #148 confirmed the odor 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 medical record review, staff interview, physician interview and review of facility policy, the facility failed to notify the physician timely of abnormal laboratory (lab) results. This affected one (#19) of three residents reviewed for notification of change. The facility census was 68. Findings include: Review of Resident #19's medical record revealed an admission date of 11/25/14. Diagnoses included dementia, anxiety, psychotic disorder, hypertension (HTN), unspecified symbolic dysfunctions, hyperosmolality and hypernatremia, chronic kidney disease (CKD) stage 3B, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/20/25, revealed a Brief Interview of Mental Status (BIMS) score was unable to be determined due to Resident #19's cognition. Further review of the medical record revealed Resident #19 had routine labs drawn on 01/15/25, including a complete metabolic panel (CMP) and a complete blood count with differential (CBC w/diff). The labs were resulted…

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 medical record review, staff interview, physician interview, Nephrology Nurse Practitioner (NNP) interview and review of facility policy, the facility failed to ensure the physician provided adequate and timely follow up for resident care needs. This affected one resident (#19) of three residents reviewed for physician services. The facility census was 68. Findings include: Review of Resident #19's medical record revealed and admission date of 11/25/14. Diagnoses included dementia, anxiety, psychotic disorder, hypertension (HTN), unspecified symbolic dysfunctions, hyperosmolality and hypernatremia, chronic kidney disease (CKD) stage 3B, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/20/25, revealed a Brief Interview of Mental Status (BIMS) score was unable to be determined due to Resident #19's cognition. Review of a laboratory (lab) report revealed Resident #19 had a routine complete metabolic panel (CMP) and a complete blood count with differential…

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, staff interview, and review of facility policy, the facility failed to ensure facility air temperatures were maintained at a comfortable and acceptable level. This affected 18 (#2, #3, #5, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29) of 68 residents residing in the facility observed for air temperatures. The facility census was 68. Findings include: Observation during tour of the facility on 12/18/24 between 10:30 A.M. and 10:51 A.M. with Maintenance Director (MD) #1 noted the facility heating ventilation and air conditioning was provided by forced air and multiple room furnaces. Each room was equipped with an electric radiant heat baseboard local control unit. Observation of ambient air temperature readings obtained in the memory care unit common corridor which contained eight (#15, #16, #17, #18, #19, #20, #21, and #22) resident's rooms was 68.7 degrees Fahrenheit (F). Located outside of Resident #15's room was a digital furnace thermostat on the wall of the common corridor. The digital reading on the thermostat was 75…

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 medical record review, staff interview, and review of the facility policy, the facility failed to ensure laboratory services were collected and completed according to the physician orders. This affected one (Resident #100) of one resident reviewed for laboratory services. The facility census was 70. Findings include: Review of the medical records for Resident #100 revealed a re-admission date of 09/05/24 and a discharge date of 10/20/24. Diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), right sided heart failure (severe), cerebral vascular accident (CVA), and alcohol abuse. Review of the current physician orders dated 10/2024 for Resident #100 revealed laboratory (lab) work was to be drawn weekly for a complete blood count (CBC) (measures the number and types of cells in your blood) and basic metabolic panel (BMP) (measures eight different substances in your blood, including electrolytes and glucose). Review of the Medication Administration Record (MAR) for Resident #100 for 09/2024 and 10/2024 revealed lab work was due 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 wound care observation, medical record review, review of the Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to ensure infection control practices were followed during wound care. This affected one (#18) of one resident observed for wound care. The facility census was 70. Findings include: Review of the medical record for Resident #18 revealed she was admitted on [DATE] with diagnoses including dementia and pressure ulcers. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively impaired and was admitted with unhealed pressure ulcers. Review of the care plan dated 10/30/24 revealed Resident #18 was care planned for wound care and enhanced barrier precautions (EBP) for wound care. Interventions included were to provide EBP as ordered (i.e. gowns, gloves, masks, goggles, etc.) to be worn by staff during the following high-contact resident care activities of wound care. Review of the current physician…

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 observations, staff, resident and family interviews and review of a housekeeping checklist, the facility failed to ensure the facility was maintained in a clean and sanitary manner. This affected four (#3, #32, #33 and #44) out of six residents sampled for the environment. The facility census was 67. Findings include: Observation on 07/17/24 from 8:45 A.M. to 9:15 A.M. of the Memory Care Unit revealed a peeling and bulging brown colored laminate floor in front of nurses station; broken and cracked wall bumpers on nurses station with jagged edges exposed to the main hallway; peeling blue carpeting on the bottom half of the wall to the left of the nurses station; six holes in the wall inside an open plastic plate to the left of the nurses station; a thick layer of dust on the fan paddles above the nurses station; peeling and missing wallpaper approximately six inches by eight inches in the hallway outside room [ROOM NUMBER]; food items on the floor in the hallway outside room [ROOM NUMBER]; deep white…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and facility medication administration policy, the facility failed to ensure medications to treat migraine headaches were provided as ordered by the physician resulting in a significant medication error. This affected one resident (#12) reviewed for the administration of medications in a facility census of 69. Findings include: Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, mononeuropathy, major depression, and cervicalgia. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #12 with intact cognition, and independent with activities of daily living. Review of the nursing plan of care dated 09/04/22, revealed it was revised to address Resident #12's acute/chronic pain related to arthritis, depression, neuropathy, overweight, gout, migraine, and muscle spasm. Interventions included: to administer analgesia as per orders.…

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, observations, staff and resident interview, and policy review, the facility failed to ensure residents were assessed for self-administration of prescription medications prior to maintaining them at bedside. This affected one (#50) of two residents reviewed for medication self-administration. The facility census was 71. Findings include: Review of the medical record for Resident #50 revealed an admission date of 08/13/19 with a diagnosis of chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition, was independently mobile with a cane, and was not resistive to care or did not demonstrate behaviors. Review of a physician order dated 01/06/22 and discontinued 01/30/24 at 1:21 P.M. revealed Resident #50 received Proair hydrofluroalkane (HFA) 90 micrograms (mcg) (200 inhalations (INH)) with directions to use two puffs inhale orally every six hours as needed for bronchospasm. There was no physician…

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 observations, interviews, record reviews and review of the facility policy, the facility failed to ensure call lights were within reach for residents identified to use call lights to request care. This affected two (#36 and #37) of eleven residents observed for call lights within reach. The facility census was 71. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 01/24/24 with diagnoses of cerebral infarction and muscle weakness. Review of the admission Nursing Observation completed 01/24/24 revealed Resident #36 was alert to person and was verbally appropriate. Review of the current care plan for Resident #36 revealed he was at high risk for falls. Interventions included keeping the call light within reach, and prompt responses to all requests for assistance. Observations on 01/30/24 between 9:18 A.M. and 9:32 A.M. revealed Resident #36 calling out for help. Observation on 01/30/24 at 9:32 A.M. revealed State Tested Nurse Aide (STNA) #107 entering Resident…

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 family and staff interview, record review, review of the appointment calendar, review of Weather Underground website, and review of the facility policy, the facility failed to provide adequate assistance with dressing for a resident who was dependent on staff with activities of daily living. This affected one (#18) of three residents reviewed for outside appointments. The facility census was 71. Findings include: Review of the medical record for Resident #18 revealed an admission date of 11/25/14 with diagnoses of dementia and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was rarely/never understood and required substantial/maximal assistance for dressing her upper and lower body. Resident #18 experienced no rejection of care or behaviors during this assessment period. Review of the current care plan, updated 10/29/23, revealed Resident #18 she had an activities of daily life self-care performance deficit. Interventions included total assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and record review, the facility failed to ensure bariatric incontinence supplies were available to allow a resident to void in a dignified manner. This affected one (#80) of three residents reviewed for bariatric supplies. Findings include: Review of the medical record for Resident #80 revealed an admission date of 01/12/24 with diagnoses of heart failure, gout, and morbid obesity. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 had intact cognition and was dependent on staff for rolling left and right and required substantial/maximal assistance for toileting and hygiene. Resident #80 was occasionally incontinent of urine and frequently incontinent of stool. Review of the progress note dated 01/12/24 at 1:28 P.M. revealed Resident #80 arrived at the facility. The progress note dated 01/12/24 at 7:58 P.M. revealed Resident #80 requested to use the bed pan, and requested a bariatric bed pan. The nurse and aide were…

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 review of the Payroll-Based Journal (PBJ) report, review of the daily posted staffing, review of employment dates, and staff interview, the facility failed to ensure Registered Nurse (RN) coverage eight hours each day. This had the potential to affect all 75 residents residing in the facility. Findings include: Review of the PBJ report for quarter two of the 2023 fiscal year revealed the facility had a high number of days without RN coverage. Review of posted daily staffing schedules from 08/27/23 through 09/27/23 revealed the facility had no RN coverage on 08/30/23, 08/31/23, 09/01/23, 09/02/23, 09/03/23, 09/04/23, 09/05/23, 09/06/23, 09/09/23, 09/10/23, 09/17/23, 09/20/23, 09/21/23, and 09/22/23. Interview on 09/26/23 at 7:20 A.M. with Regional Clinical Director (RCD) #362 revealed she learned on 09/22/23 the facility had a RN on-call on the weekends but did not have a RN scheduled and working in the facility for eight hours on Saturdays and Sundays. Interview on 09/27/23 at 10:50 A.M. the Administrator verified the facility reviewed RN staffing coverage from 06/01/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview the facility failed to ensure medications were securely stored on the memory care unit. This affected one (#29) of one residents reviewed for medication storage and had the potential to affect 13 (#3, #5, #6, #21, #32, #36, #50, #53, #58, #64, #65, #122, and #127) additional cognitively impaired and independently mobile residents identified by the facility residing on the secured memory care unit. Additionally, the facility failed to ensure fall interventions were implemented as care planned. This affected two (#8 and #172) of four residents reviewed for falls. The facility census was 75. Findings include: 1. Review of Resident #29's medical record revealed an admission date of 08/25/20. Diagnoses included atherosclerotic heart disease, congestive heart failure (CHF), unspecified protein-calorie malnutrition, atrial fibrillation, major depressive disorder, peripheral vascular disease, dementia, and chronic obstructive pulmonary disease (COPD). Review…

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, medical record review, resident interview, staff interview, and review of pharmacy delivery manifest, the facility failed to obtain medications as prescribed by the physician for administration. This affected five (#17, #25, #59, #57, and #71) of six residents observed and reviewed for the provision of medications. Facility census was 75. Findings include: 1. Observation on 09/26/23 at 9:15 A.M. noted Licensed Practical Nurse (LPN) #331 assembling Resident #17's morning medications. LPN #331 stated Resident #17's Norco 5-325 milligrams (mg) was not available and proceeded to contacted the facility pharmacy via telephone at 9:20 A.M. Review of Resident #17's medical record revealed Norco 5-325 mg was ordered on 07/29/23 to be administered four times a day at 9:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M. On 09/26/23 at 9:23 A.M. interview with LPN #331 revealed Resident #17's Norco 5-325 mg medication was not available from the pharmacy and would not be administered. 2. Observation on 09/26/23…

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

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure the administration of medications with an error rate of less than five percent. A total of 15 errors were observed during 30 opportunities for a medication error rate of 50%. This affected five (#16, #17, #25, #17, #57, #59) of six residents observed during medication administration. The facility census was 75. Findings include: 1. Observation on 09/26/23 at 9:15 A.M. noted Licensed Practical Nurse (LPN) #331 assembling Resident #17's morning medications. LPN #331 stated Resident #17 Norco 5-325 milligrams (mg) was not available and proceeded to contacted the facility pharmacy via telephone at 9:20 A.M. At 9:23 A.M. LPN #331 stated Resident #17 Norco 5-325 mg medication was not available from the pharmacy and would not be administered. Review of Resident #17's medical record revealed Norco 5-325 mg was ordered on 07/29/23 ad to be administered four times a day at 9:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M. 2. Observation on 09/26/23 at 9:53 A.M. noted LPN #331…

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, medical record review, staff interview, and review of facility policy, the facility failed to provide medications in accordance with physicians orders which resulted in medication significant medication errors. This affected four (#17, #25, #57, and #71) of six residents observed and reviewed for medication administration. Facility census was 75. Findings include: 1. Observation on 09/26/23 at 9:15 A.M. noted Licensed Practical Nurse (LPN) #331 assembling Resident #17's morning medications. LPN #331 stated Resident #17 Norco 5-325 milligrams (mg) was not available and proceeded to contacted the facility pharmacy via telephone at 9:20 A.M. At 9:23 A.M. LPN #331 stated Resident #17 Norco 5-325 mg medication was not available from the pharmacy and would not be administered. Review of Resident #17's medical record revealed Norco- 5-325 mg was ordered on 07/29/23 ad to be administered four times a day at 9:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M. 2. Observation on 09/26/23 at 10:05 A.M. noted…

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 medical record review, staff interview, review of Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policy, the facility failed to ensure residents were offered pneumococcal vaccines per CDC guidelines. This affected five (#3, #9, #21 #30, and #32) of five residents reviewed for pneumococcal vaccinations. The facility census was 75. Findings include: 1. Review of Resident #3's medical record revealed an admission date of 02/27/23. Diagnoses included paranoid personality disorder, hypertension, edema, dementia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/18/23, revealed Resident #3 was severely cognitively impaired. Additionally, Resident #3 was not up to date on pneumococcal vaccination and the vaccination had been offered and declined. Review of Resident #3's immunization record revealed the resident received Prevnar 13 on 07/20/16. Additional review revealed no evidence Resident #3 received a dose of PCV20 or…

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

Based on medical record review, family and resident interview, observation and staff interview, the facility failed to honor a resident's choice to get out of bed. This affected one (#8) out of four residents reviewed for activities of daily living The facility census was 75. Findings include: Review of the medical record for Resident #8 revealed an admission date of 08/02/23. Diagnoses included quadriplegia, spastic cerebral palsy, convulsions, pressure ulcers, and contracture to right hand. Review of the MDS assessment, dated 08/07/23, revealed Resident #8 was rarely/never understood and was dependent on two people for transfers. Observations on 09/25/23 at 9:50 A.M., 2:27 P.M., and 3:23 P.M. revealed Resident #8 lying in bed. Interview on 09/25/23 at 2:13 P.M. with Resident #8's brother revealed the family would like Resident #8 out of bed at least four hours per day due to a previous urologist's recommendation to decreased Resident #8's risk of kidney stones. Observations on 09/26/23 at 9:21 A.M., 11:28 A.M., 12:51 P.M., 1:56 P.M., 3:13 P.M., and 4:00 P.M. revealed Resident #8…

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 staff interview, record review, and review of the facility policy, the facility failed to obtain written authorizations by the resident or representative to open a Resident Trust account. This affected two (#53, #16) of six residents reviewed for Resident Trust accounts. The facility census was 75. Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 12/08/21. Review of the quarterly statement documentation, Resident #53 had an established trust account with transactions dating between 04/01/23 and 08/03/23. The current balance was $500.48. No written authorization was provided stating Resident #53 authorized the facility to manage a resident trust account. 2. Review of the medical record for Resident #16 revealed a readmission date of 03/20/20. Review of the quarterly statement documentation, Resident #16 had an established trust account with transactions dating between 04/01/23 and 08/17/23. The current balance was $1,143.15. No written authorization was provided stating Resident #16 authorized the facility to manage a resident…

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 medical record review, staff interview, and review of facility policy, the facility failed to ensure the current code status was present on both the electronic medical record (EMR) and the paper medical record (PMR) for two (#122 and #24) of two residents reviewed for advanced directives. The facility census was 75. Findings include: 1. Review of Resident #122's medical record revealed an admission date of 09/22/23. Diagnoses included non-pressure chronic ulcer of other part of left foot limited to breakdown of skin, altered mental status, dementia, hypertension, and osteoarthritis. Review of the Electronic Medical Record (EMR) and Paper Medical Record (PMR) revealed no documentation of Resident #122's code status. Interview on 09/26/23 at 7:30 A.M. with Licensed Practical Nurse (LPN) #361 revealed a resident's code status should be in both the EMR and PMR. LPN #361 looked at Resident #122's EMR and verified the resident's code status was not present. LPN #361 began looking through Resident #122's PMR and found code status sheets for both Full Code and Do Not Resuscitate in…

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

Based on staff interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation was completed for one (#27) of three residents reviewed for PASRR evaluations. The facility census was 75. Findings include: Review of the medical record for Resident #27 revealed an admission date of 03/26/22 with diagnoses of encephalopathy and schizophrenia. Review of a PASRR Result Notice dated 03/23/22 revealed Resident #27 was referred for a Level 2 evaluation. Review of a document titled PASRR Outcome Explanation Determination, dated 04/11/22, revealed the Level 2 evaluation could not be completed because the information required information was not available to complete a determination. Interview on 09/26/23 at 7:46 A.M. with Social Services Director #311 confirmed a PASRR Level 2 evaluation was not completed as requested on 03/23/22 for Resident #27. Interview on 09/28/23 at 7:55 A.M. with the Administrator revealed the Social Services Director was responsible for completing PASRR screening and evaluations. The Administrator and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure dependent residents were provided with scheduled bathing and effective hygiene. This affected three (#16, #25, #61) of 29 residents reviewed for activities of daily living (ADL) and hygiene. Facility census 75. Findings include: 1. Review of the medical record revealed Resident #16 admitted to the facility on [DATE]. Diagnoses included Huntington's disease, anxiety disorder, gastrostomy, cerebral infarction, dysphagia, protein calorie malnutrition, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 09/04/23, Resident #16 was assessed with severely impaired cognition and was dependent on staff for completion of activities of daily living. Review of the care plan dated 02/08/21 revealed Resident #16 had an ADL self-care performance deficit related to disease process, Huntington's disease, and cerebral vascular accident. Interventions included the resident was dependent on staff to provide bath or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure activities who were in bed were provided activities of interest. This affected two (#16 and #8) of two residents reviewed for the provision of activities in a facility census of 75. Findings include: Review of the medical record revealed Resident #16 admitted to the facility on [DATE]. Diagnoses included Huntington's disease, anxiety disorder, gastrostomy, cerebral infarction, dysphagia, protein calorie malnutrition, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 09/04/23, revealed Resident #16 was assessed with severely impaired cognition and adequate vision and hearing. Review of the plan of care dated 09/30/21 revealed Resident #16 was dependent on staff for meeting emotional, intellectual, physical, and social needs secondary to physical limitations. Interventions included staff to converse with resident while providing care, ensure the activities the resident is attending are compatible 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, family interview, staff interview, and review of the medical record, the facility failed to ensure interventions were in place to maintain range of motion (ROM). This affected one (#8) of one resident reviewed for range of motion. The facility census was 75. Findings include: Review of the medical record for Resident #8 revealed an admission date of 08/02/23 with diagnoses of quadriplegia, spastic cerebral palsy, convulsions, and contracture to right hand. Review of the Minimum Data Set (MDS) assessment, dated 08/07/23, revealed Resident #8 had functional limitation in ROM on one side of his upper body and no impairment to ROM to his lower extremity. Review of the Occupational Therapy Discharge Summary for Resident #8, dated 08/18/23, revealed recommendations to place wash cloths in both hands to keep digits from touching palm of hands. Review of the care plan and physicians orders revealed no interventions for the use of a wash cloth to Resident #8's hands. Observation on 09/25/23 at 9:50 A.M. revealed Resident #8 lying in bed. Resident #8's right hand…

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, staff interview, review of the medical record, and review of supply invoices, the facility failed to provide nutrition supplements as ordered by the physician. This affected one (#29) of one resident reviewed for nutrition supplements. The facility identified five residents who receive the nutrition supplement. Further, the facility failed to obtain weekly weights and ensure adequate water was provided to a resident with an enteral tube. This affected one (#8) of two residents reviewed for feeding tubes. The facility census was 75. Findings include: 1. Review of Resident #29's medical record revealed an admission date of 08/25/20. Diagnoses included atherosclerotic heart disease, congestive heart failure (CHF), unspecified protein-calorie malnutrition, atrial fibrillation, major depressive disorder, peripheral vascular disease, dementia, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/06/23, revealed Resident #29 was moderately cognitively impaired. Review of a plan of care focus area,…

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 medical record review, observation and staff interview, the facility failed to ensure an abdominal binder was in place to secure a gastrostomy tube (Gtube) and prevent leakage for one (#16) out of two residents reviewed for Gtubes. The facility census was 75. Findings include: Review of the medical record revealed Resident #16 admitted to the facility on [DATE]. Diagnoses included Huntington's disease, anxiety disorder, gastrostomy, cerebral infarction, dysphagia, protein calorie malnutrition, and dementia. Review of the Minimum Data Set assessment, dated 09/04/23, revealed Resident #16 was assessed with severely impaired cognition and receives nutrition via tube feeding. Review of physician orders noted on 04/27/23 a physician order was initiated for an abdominal binder to secure gastrostomy tube every shift. Review of nurses notes dated 09/07/23 at 7:31 P.M. revealed nurse was informed by aide the patient's tube feeding leaked into bed. Nurse went into room to assess resident. Top of the Gtube opening…

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, medical record review, staff interview, and review of facility policy, the facility failed to ensure supplemental oxygen was administered only with a physician's order and failed to ensure tracheostomy care was provided per physician orders. This affected two (#25, #46) of two residents reviewed for respiratory care and services. Facility census 75. Findings include: 1. Review of the medical record revealed Resident #25 admitted to facility on 03/01/23. Diagnoses included chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, chronic respiratory failure, atrial fibrillation, congestive heart failure, dementia, major depression, coronary heart disease, hypertension, inflammatory disease of prostate, anxiety, and chronic hepatitis. According to the minimum data set assessment dated [DATE] assessed Resident #25 with ability to make needs known, intact cognition, requires assistance from staff with bathing, dressing, set-up help with hygiene, and received oxygen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and pharmacy delivery manifest, the facility failed to place accurate documentation within the contents medical record. This affected three (#29, #45, and #71) of 23 residents reviewed for medical record entries in a facility census of 75. Findings include: 1. Review of Resident #71's medical record revealed an admission date of 08/09/23 and a discharge date of 08/31/23. Diagnoses included metabolic encephalopathy, cirrhosis of liver, ascites, nontraumatic subarachnoid hemorrhage, chronic obstructive pulmonary disease (COPD), hepatic failure, depression, hemiplegia and hemiparesis, and cognitive communication deficit. Review of physician orders revealed Resident #71 was ordered Xifaxan oral tablet 550 milligrams (mg) one tablet by mouth two times a day for cirrhosis of the liver. Review of the Medication Administration Record (MAR) from 08/09/23 through 08/27/23 revealed xifaxan was documented as administered on 08/10/23 and both morning and evening…

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, family interview, and staff interview, the facility failed to ensure residents rooms were maintained in a clean, comfortable, and homelike environment. This affected four (#8, #27, #28, and #52) of five residents reviewed for a homelike environment. The facility census was 75. Findings include: 1. Observation of Resident #8's room and interview on 09/26/23 at approximately 11:00 A.M. with Regional Maintenance #365 confirmed the wallpaper alongside Resident #8's bed was torn. The tears covered approximately one-third of the wall space alongside Resident #8's bed. Observation and interview on 09/26/23 at 4:00 P.M. with Resident #8's sister revealed Resident #8 faced the window and the blinds on the windows did not function with the pull cords. Resident #8's sister moved each blind by hand so Resident #8 could see out the window. During the observations and interview wth Resident #8's sister beginning on 09/26/23 at 4:00 P.M., Regional Maintenance #365 entered the room and confirmed the blinds did not function with the pull cord. 2. Observation on 09/25/23 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, resident interview, and staff interview, the facility failed to maintain an effective pest control program. This affected two (#28 and #29) of three residents reviewed for pest control with the potential to affect all residents of the facility. The facility census was 75. Findings include: Observation on 09/25/23 at 11:03 A.M. of Resident #29's room revealed seven styrofoam cups on the floor next to the bed. Approximately three flies were observed around the resident's bed and cups. Observation on 09/26/23 at 9:37 A.M. of Resident #29's room revealed multiple flies in the room. Concurrent interview of Resident #29 revealed the resident stated I have two flies in here and I can't get rid of them. I don't like them. Observation on 09/26/23 at 12:06 P.M. revealed Resident #29 sitting in the dining room on the secured memory care unit. Resident #29's lunch meal was sitting in front of her. A fly was observed to land on the resident's vegetables. Resident #29 swatted the fly away. Interview on 09/25/23 at 12:34 P.M. of Licensed Practical Nurse (LPN) #302 verified…

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, medical record review, staff interview, resident interview, review of Centers for Medicare and Medicaid Services (CMS) guidance, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure two residents (#108 and #109) were not involuntary secluded to their rooms unnecessarily. Additionally, the facility failed to resume communal dining. This had the potential to affect all residents of the facility with the exception of three residents (#12, #20, and #39) who were identified as not receiving food from the kitchen. The facility census was 61. Findings include: 1. Review of Resident #108's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included complete traumatic amputation between right hip and knee, chronic obstructive pulmonary disease (COPD), schizoaffective disorder, major depression, anxiety, and bipolar disorder. According to the clinical health status assessment dated [DATE], Resident #108 was…

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

Based on review of the scheduled meal times, observation and staff interview the facility failed to maintain adequate staffing in the kitchen to ensure meals were served in a timely manner. This affected all residents who eat their meals provided from the kitchen. The facility identified three residents (#12, #20, and #39) who did not receive food from the kitchen. The facility census was 61. Findings include: Observation of the lunch meal on 05/17/21 revealed the meal cart arrived on the 100 hall at 12:20 P.M. Observation of the 200 hall revealed the meal cart had not arrived until 1:00 P.M. Further observation of the 300/400 halls, revealed the meal cart arrived at 1:10 P.M. Multiple residents were observed sitting in the doorways to their rooms asking when their lunches were coming. Interview with Dietary Aide #200 on 05/17/21 at 3:15 P.M. revealed the lunch meal should have been started at 11:30 A.M. and arrived to the floors by 12:00 P.M. She further stated there was only herself and the cook today and there should have been two dietary aides. She verified the lunch trays for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, policy review, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to adhere to the following recommended infection control practices for preventing the spread of Coronavirus 2019 (COVID-19) related to ensuring new resident admissions were placed on transmission-based precautions for the recommended 14 days. This affected one resident (#46) of six new resident admissions. In addition, the facility failed to ensure a urinary collection device was properly stored for Resident #46. This had the potential to affect one resident (#39) who shared the same bathroom. Lastly, the facility failed to ensure a Coronavirus Disease 2019 (COVID-19) vaccine was offered to one resident (#12) of three reviewed for vaccine status. The facility census was 61. Findings Include: 1. Review of Resident #46's medical record revealed an admission date of 01/19/21. The resident was discharged to the hospital on [DATE] and re-admitted…

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, medical record review, staff interview, resident interview, and facility policy review, the facility failed to properly assess and provide appropriately fitting, physically intact resident wheelchairs, chairs and bed. This deficient practice affected three residents (#41, #109, #12) of 24 reviewed for furniture and assistive devices. The facility census was 61. Findings include: 1. Medical record review revealed Resident #41 admitted to the facility on [DATE] with the diagnoses including, history of stage 4 pressure ulcer to the sacral region and stage 2 diabetic ulcer to the foot, cellulitis right lower limb, and hyperlipidemia. According to the most current minimum data set (MDS) assessment dated [DATE] Resident #41 was identified as having intact cognition. Review of a 04/28/21 physical therapy (PT) evaluation noted Resident #41 to be seen three to five times weekly for four weeks using therapeutic exercises, therapeutic activity, neuromuscular re-education, wheelchair management. 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 medical record review, staff interview, interview with resident's representative, and Centers for Disease Control and Prevention (CDC) Coronavirus Disease 2019 (COVID-19) Pandemic guidance, Centers for Medicare and Medicaid Services (CMS) recommendations, the facility failed to ensure residents were provided with in-person visitation opportunities. This deficient practice affected one resident (#25) of three reviewed for family visitation. The facility census was 61. Findings include: 1. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including, dementia, muscle weakness, lack of coordination, cognitive communication deficit, chronic kidney disease, Alzheimer's disease, Covid-19, and anxiety. According to the most current minimum data set(MDS) assessment dated [DATE] identified the resident with severe cognitive impairment. On 05/18/21 at 11:15 A.M. interview with Licensed Practical Nurse (LPN) #200 and LPN #201 revealed Resident #25's granddaughter 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, medical record review, staff interview, and review of facility resident smoking policy, the facility failed to complete accurate resident smoking assessments and monitor for smoking compliance for one resident (#43) to ensure resident safety. Additionally, the facility failed to ensure one resident (#44) had elopement prevention devices applied as ordered by the physician. This affected two residents (#43 and #44) of 24 residents reviewed for the potential for elopement and safe smoking in a facility census of 61. Findings include: 1. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including, dementia, lack of coordination, bipolar disorder, paranoid schizophrenia, delusional disorder, chronic obstructive pulmonary disease (COPD) and coronary heart disease. According to the most current minimum data set (MDS) assessment dated [DATE] Resident #43 was identified with severe cognitive impairment. Review of the safe smoking evaluation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure a resident's access to dialysis (fistula) was assessed and documented daily. This affected one resident (#34) of one reviewed for dialysis. The facility was 61. Findings include: Review of the medical record for Resident #34 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), and end stage renal dialysis with dependence on renal dialysis. Review of the plan of care for Resident #34 dated 11/0718 revealed the resident did receive dialysis three days a week. It was noted the resident had a fistula (surgically implanted dialysis access site) which was to be assessed by nursing staff for functioning (thrill and bruit) daily. There was no evidence in the resident's medical record the fistula was assessed. Interview with Resident #34 on 05/17/21 at 3:00 P.M. revealed nursing staff did not routinely check his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, policy review, and manufacturer recommendations for use instructions the facility failed to ensure medications were administered as ordered. There were 27 opportunities were observed with eight medication errors for a calculated medication error rate of 29.63%. This affected two residents (#33, #41) of four residents reviewed for medication administration. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, muscle weakness, hypertension, chronic obstructive pulmonary disease, abnormal posture, congestive heart failure, peripheral vascular disease, major depression, history of urinary tract infection, and supra-pubic urinary catheter. Observation on 05/18/21 at 8:11 A.M. revealed Licensed Practical Nurse (LPN) #200 prepared medications for Resident #33. Medications included one 81 milligram (mg) chewable aspirin, two 4%…

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 medical record review, observation, staff interview, policy review, and manufacturer recommendations for use the facility failed to ensure the administration of insulin included the proper dosage which resulted in a significant medication error for one resident (#41) of four residents reviewed for medication administration. The facility census was 61. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included diabetes. Review of the physician orders dated 05/21/20 revealed an order for Lantus Solos Injection Insulin Gargine Solution inject eight units subcutaneous every 12 hours, and order dated 04/19/21 revealed Novolog Injection Flexpen Insulin Aspart Solution inject per sliding scale four times daily. Sliding scale blood sugar 0 milligrams per deciliter (mg/dL) to 199 mg/dL give zero units, 200 mg/dL to 249 mg/dL give two units, 250 mg/dL to 299 mg/dL give three units, 300 mg/dL to 349 mg/dL give four units, 350 mg/dL and over give…

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 medical record review, staff interview, and policy review the facility failed to ensure physician ordered laboratory testing was obtained in a timely manner. This affected two residents (#33 and #32) of 24 reviewed for laboratory testing. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, muscle weakness, hypertension, chronic obstructive pulmonary disease, abnormal posture, congestive heart failure, peripheral vascular disease, major depression, history of urinary tract infection, and supra-pubic urinary catheter. Review of the nursing plan of care revised date 02/14/21 to address the residents diagnosis of Multiple Sclerosis. Interventions included give medications as ordered, monitor/document for side effects and effectiveness, monitor/document/report to physician as needed signs and symptoms of damage to motor and sensory control centers: urinary frequency, urgency or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, and policy review the facility failed to ensure residents received offered ancillary dental services. This affected one resident (#38) of one resident reviewed for dental services, who had poor oral health. The facility identified 42 residents who received dental services provided by the facility's ancillary dental service. The facility census was 61. Findings include: Review of the medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included muscle disorder, chronic low back pan, psychoactive substance abuse, chronic pressure ulcers, adjustment disorder with mixed anxiety and depressed mood, colostomy status, neuromuscular dysfunction of the bladder, paraplegia and bilateral above the knee amputations. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficits, had rejection of care four to six days of the assessment period. The resident…

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 medical record review, observation, and staff interview the facility failed to provide rehabilitation therapy to maintain functional abilities. This affected one resident (#109) of two residents reviewed for rehabilitation services and new admission. The facility census was 61. Findings include; Review of the medical record revealed Resident #109 was admitted to the facility on [DATE]. Diagnoses included severely comminuted distal femur fracture periprosthetic with surgical correction, muscle weakness, periprosthetic fracture around internal prosthetic left hip, chronic obstructive pulmonary disease, morbid obesity, type 2 diabetes mellitus, hypertensive chronic kidney disease, anemia, hypothyroidism, anxiety disorder, sleep apnea, osteoarthritis, pulmonary nodule and history of falling. Review of the minimum data set (MDS) assessment dated [DATE] identified the resident was alert, oriented, able to make needs known with a brief interview for mental status score of 14 indicated intact cognition. 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.