Emerald Care Center Midwest

Based on observation and interview, the facility failed to have a call system available for resident use in one of three shower rooms observed. The DON reported 68 residents resided in the facility. Findings: On 04/10/25 at 9:40 a.m., the shower room on hall 400 was observed to have one sink, one toilet, and two shower stalls. The shower room had no call system available. On 04/10/25 at 9:57 a.m., CNA #2, checked the shower room on hall 400 and reported no call system was available. On 04/10/25 at 11:46 a.m., the maintenance supervisor reported they were unaware the shower room on the 400 hall did not have a call system. The maintenance supervisor reported the shower room should have a call system available for residents to call for assistance.

Based on observation, record review, and interview, the facility failed to ensure the exterior building was maintained in good repair. The administrator identified 68 residents resided in the facility. Findings: On 04/10/25 at 9:55 a.m. through 10:10 a.m., a tour of the outside was conducted. There were 25 areas of rotted soffit boards and peeling paint around the whole parameter of the building. The undated facility Maintenance Manager job description, read in part, The primary purpose of the job description is to plan, organize, develop, and direct the general and preventative maintenance of the physical plant and grounds. On 04/10/25 11:39 a.m., the administrator stated the job description was all the facility had. The administrator stated they did not make rounds outside except on the patio and they were not aware of all the areas of rotted soffit boards. On 04/10/25 11:44 a.m., the maintance director stated they walked around the facility daily. They stated they had put requests into corporate to have the soffits fixed since they had been employed three years ago. 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 record review and interview, the facility failed to ensure an order for pain medication was submitted to the pharmacy in a timely manner for 1 (#1) of 3 sampled residents reviewed for having pain medications ordered in a timely manner. The administrator identified 65 residents resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses which included status post thrombectomy of right superficial femoral, profunda femoral, and popliteal arteries. A physician's order, dated 01/23/25, showed Resident #1 was to receive hydrocodone/APAP (pain medication) tab 5-325 mg one tab every four hours as needed for complaints of pain. On 01/30/25 at 9:07 a.m., Resident #1 reported the facility took two days after they were admitted to get anything stronger than Tylenol (pain reliever) for complaints of pain. On 01/30/25 at 9:20 a.m., certified medication aide #1 stated Resident #1 received an order for a narcotic pain medication on 01/23/25, but they were not sure why it took…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure: a. incident reports involving residents were accessible to the SA for two (#1 and #7); and b. resident records were complete and accurate for two (#1 and #7) of three sampled residents reviewed for falls. The wound care nurse identified 57 residents resided in the facility. The Incidents by Incident Type reports, dated 11/14/24, documented 30 residents experienced a fall for the months of September, October, and November 2024. Findings: An Accidents and Incidents policy, dated 01/24, read in part, Accidents/incidents may include .Fall .A thorough investigation and follow-up will be completed within five working days. A summary of the accident/incident will be documented .Accident/incident will have documentation initiated by the individual witnessing, made aware of or involved in the occurrence as soon as discovered or reported. An Incident investigation is not punitive in nature, but simply an accurate, objective account of an occurrence…

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

Based on record review and interview, the facility failed to provide evidence a resident representative was notified after the resident experienced a fall for one (#7) of three sampled residents reviewed for falls. The wound care nurse identified 57 residents resided in the facility. The Incidents by Incident Type reports, dated 11/14/24, documented 30 residents experienced a fall for the months of September, October, and November 2024. Findings: A Notification of Changes policy, dated 01/24, read in part, It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or representative .When a resident is mentally competent, his or her designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident .Requirements for notification of resident, the resident representative, their physician .An accident involving the resident, which…

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

Based on record review and interview, the facility failed to ensure a resident's critical post discharge medical equipment was ordered and received in a timely manner for one (#1) of two sampled residents whose discharge planning process was reviewed. The DON identified 65 residents resided in the facility. Findings: Resident #1 was admitted to facility on 04/17/24 with diagnoses that included Parkinsonism, traumatic subdural hematoma, and depression. A 'Notice of Medicare Non-Coverage', was signed by Resident #1 on 04/29/24. A Nursing Progress Note, written 05/02/24, documented Resident #1 was discharged home with family. A Physician's Progress Note, submitted to the DME company, read in parts, .Without a wheelchair, the patient has a higher risk of morbidity or mortality in [their] attempts to complete [their] MRADLs . It was not signed by NP #1 nor submitted to the DME company until 05/09/24. A prescription for billing and dispensing of a standard wheelchair for Resident #1 was not signed by NP #1 nor submitted to the DME company until 05/09/24. There was no documentation in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to administer medications and treatments in a timely manner for two (#4 and #5) of six residents reviewed for receiving medications and treatments for scabies. The DON identified 65 residents resided in the facility. Findings: 1. A Physician's Order for Resident #4, dated 05/29/24, read in parts, .Ivermectin Oral Tablet 3mg .give 7 tablets by mouth one time only for rash . Pharmacy Manifest #2761767, dated 05/31/24, documented Ivermectin 3mg tabs (7 tabs) were delivered to the facility on [DATE] at 7:20 p.m. and received by LPN #1. A printout of the medication administration history for Resident #4 documented Ivermectin 3mg tabs (7 tabs) were not administered until 06/06/24 at 3:58 p.m. There was a lapse of 140.25 hours (5 days and 20.25 hours) between the time Resident #4's medication was delivered to the facility and when it was administered. 2. A Physician's Order for Resident #5, dated 06/11/24, read in parts, .Permethrin External Cream 5% .Apply 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 record review and interview, the facility failed to administer treatment as ordered for one (#5) of six sampled residents reviewed for receiving medication or treatment for scabies. The DON identified 65 residents resided in the facility. Findings: A Physician's Order, dated 06/11/24, read in parts, .Permethrin External Cream 5% .Apply to body-neck down topically one time only for rash for 2 Days .leave on for 8 hours and then shower . June 2024 MAR documented Permethrin Cream 5% was administered on 06/13/24 at 1:38 a.m. On 06/14/24 at 9:20 a.m., Resident #5 was asked if Permethrin Cream 5% had been applied to their body for a second time during the previous night and if they had been showered this am. Resident #5 stated, No, they only did it that one time. Resident #5 was asked if they still had itching or a rash. They stated yes and showed left arm and left chest to this surveyor. Several red, raised areas were observed on Resident #5's left arm and chest. On 06/14/24 at 9:28 a.m., CNA #1 was asked if Resident #5 had received a shower this morning to remove medication…

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

Based on record review and interview, the facility failed to ensure staff notified the physician of a resident with an ongoing rash and no treatment prescribed for one (#6) of six residents reviewed for infection control. The Administrator identified 59 residents resided in the facility. Findings: A Notification of Changes Policy, dated 01/2024, read in part, .Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure the best outcomes of care for the resident . Resident #6 had diagnoses which included dementia, high blood pressure and dermatitis. A nurse progress note, dated 01/02/24 at 7:01 p.m., read in part .Resident noted to have rashes all over the body which were gotten worse with resident constantly scratching d/t itchiness. PCP was notified .new order for Clobetasol cream to be applied for 14 days twice a day . The January 2024 TAR documented Resident #6 was treated with the Clobetasol cream from 01/03/24 through…

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

Based on record review and interview, the facility failed to implement their infection control policy for surveillance of scabies for four (#3, 4, 5 and #36) of six sampled residents reviewed for infection control. The Administrator identified 59 residents resided in the facility. Findings: An Infection Control-surveilance for infection policy, revised 01/2024, read in part .The Infectionist Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections .that have substantial impact on potential resident outcome and that may require transmission based precautions and other preventative interventions .Infections that include routine surveillance include those with .Pathogens associated with serious outbreaks .scabies . 1. Resident #3 had diagnoses which included congestive heart failure and sarcopenia. A Derm Visit note, dated 02/05/24, read in part .Rash located on [the residents] Upper body;scalp;neck for several months. Scabies vs atopic derm vs other .Rash: located on upper body;arms .Will treat as scabies . 2. Resident #4 had diagnoses which included, type…

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

Based on record review and interview, the facility failed to implement their abuse policy for three (#4, 13, and #14) of four sampled residents reviewed for abuse. The DON identified 63 residents resided in the facility. Findings: An Abuse policy, dated 01/2024, documented residents must not be subject to abuse by anyone. It documented, in response to abuse, the facility must report it immediately to the Administrator, other officials in accordance with State law, and State Survey and Certification agency. It documented, when suspicion of abuse occurs, an investigation is immediately conducted. 1. Resident #4 had diagnoses which included anxiety disorder. An Annual assessment, dated 08/21/23, documented Resident #4's cognition was intact. A Witness Statement, dated 11/07/23, documented Resident #4 told CNA #5 on 11/06/23 a staff member yelled at Resident #4 on 11/03/23. A Resolution Form, dated 02/15/24, documented Resident #4 reported the housekeeping supervisor was verbally abusive. The resolution from staff read in part, .All residents .who were cognitive have been interviewed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administer medication as ordered: a. for one (#9) of five sampled residents reviewed for unnecessary medications; and b. for one (#48) of five sampled residents observed during medication pass. The DON identified 64 residents resided in the facility. Findings: The Medication Administration and General Guidelines policy, dated 2021, read in part, .Medications are administered in accordance with written orders of the attending physician .Medications are administered within one hour of the scheduled time . 1. Resident #9 had diagnoses which included hypertension and Dementia. A physician's order, dated 07/20/23, documented Donepezil HCl oral tablet 5 mg give one tablet by mouth at bedtime related to Dementia. A physician's order, dated 07/24/23, documented metoprolol tartrate oral tablet give 12.5 mg by mouth two times a day related to hypertension. The October 2023 medication administration record documented; a. Donepezil HCl 5mg had no notation or waiting on pharmacy on 10/10/23, 10/21/23, 10/22/23, 10/23/23,…

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 record review, observation, and interview, the facility failed to ensure a significant medication error did not occur for one (#9) of five sampled residents for unnecessary medication regimen review. The DON identified 64 residents resided in the facility. Findings: The Medication Administration and General Guidelines policy, dated 2021, read in part, .Medications are administered in accordance with written orders of the attending physician . The Medication Discrepancies and Adverse Medication Reactions policy, dated 2021, read in part, .Medication Discrepancy .It is also an omission of an ordered medication due to prescribing, dispensing, or administering error . Resident #9 had diagnoses which included chronic atrial fibrillation, chronic diastolic (congestive) heart failure, hypertension, and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Physician's orders, dated 07/20/23, documented the following medications: a. Eliquis (anticoagulant) 5 mg two times a day for chronic atrial fibrillation, and b. furosemide (diuretic) 20 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, record review, and interview, the facility failed to ensure: a. the ice machine was in sanitary condition in accordance with professional standards for food safety and service for one of two ice machines observed; and b. food was handled under sanitary conditions in accordance with professional standards for food safety and service for one of one kitchen observations. The DON identified 63 residents received nutritional services from the kitchen in the facility. Findings: An undated Equipment food-contact surfaces and utensils facility policy, read in part, .equipment food-contact surfaces and utensils shall be cleaned and sanitized .at a frequency necessary to preclude accumulation of soil or mold . An undated Gloves, use limitation facility policy, read in part, .single use gloves shall be used for only one task .and discarded when damaged or soiled, or when interruptions occur in the operation . On 12/11/23 at 8:38 a.m., the ice machine in the dining room was observed to be dripping water, with a white substance all over the dispense funnel, drainage panel…

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

Based on record review and interview, the facility failed to complete pre-employment screening for history of abuse and neglect per their abuse policy for one (housekeeping and laundry supervisor) of five employee files reviewed. The current employee list, undated, documented 97 facility employees. Findings: The facility's Abuse Protection policy, revised on 05/03/22, read in part, .It is the policy of the facility to ensure residents are free from abuse .The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property .Our facility conducts employee background checks .Screening-Protocols for conducting employment background checks: background checks include State Criminal, Federal Criminal .reference checks, OIG check, Sex Offender check, and any other review required under State or Federal regulation . Housekeeping and laundry supervisor had a hire date of 10/02/23. The OK Screen for housekeeping and laundry supervisor was dated 12/13/23. On 12/13/23 at 10:48 a.m., the HRD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nutrition via tube feeding was administered as ordered for one (#55) of five sampled residents observed during medication pass. The DON identified 64 residents resided in the facility and two residents received their nutrition through tube feeding. Findings: The Care and Treatment of Feeding Tubes policy, dated 11/17, read in part, .Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush . Resident #55 had diagnoses which included gastrostomy and protein calorie malnutrition. A physician's order, dated 12/08/23, documented enteral feed order every shift for continuous peg feedings glucerna 1.2 at 70 ml per hour with 23 ml per hour flush of water. On 12/12/23 at 12:41 p.m., Resident #55's tube feeding pump setting was observed with glucerna 1.2 at 70 ml per hour and water flush 30 ml every zero hours. The water bag was dated 12/11/23. On 12/12/23 at 12:53 p.m.,…

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

Based on observation, record review and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 25 opportunities were observed with two errors. The total medication error rate was 8%. The DON identified 64 residents resided in the facility. Findings: The Medication Discrepancies and Adverse Medication Reactions policy, dated 2021, read in part, .Medication Discrepancy .It is also an omission of an ordered medication due to prescribing, dispensing, or administering error . Resident #55 had diagnoses which included hypertension, syncope, and collapse. A physician's order, dated 11/20/23, documented amlodipine Besylate 10 mg give one tablet by mouth one time a day for hypertension hold and notify MD if systolic blood pressure below 100, or diastolic blood pressure below 60, or pulse below 55. A physician's order, dated 11/20/23, documented carvedilol oral tablet 6.25 mg give one tablet by mouth two times a day for hypertension hold and notify MD if systolic blood pressure below 100, or diastolic blood pressure below 60, or pulse below 55. 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 record review, observation and interview, the facility failed to ensure residents received a therapeutic diet as ordered for one (#163) of two sampled residents reviewed for nutrition. The DON identified 64 residents resided in the facility. Findings: The facility's Therapeutic Diet Orders policy, dated 11/17, read in part, .To assure residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his/her goals and preferences .2. Therapeutic diets will be provided to residents in the appropriate nutritive content as prescribed by the physician and/or assessed by the interdisciplinary team to support the treatment and plan of care. Resident #163's diagnosis included Diabetes type II, hyperlipidemia, hypertension and calculus kidney. A Physician Order, dated 12/01/23, documented resident #163 was to receive a consistent carbohydrate controlled diet. On 12/12/23 at 10:11 a.m., during a 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.

Based on record review and interview, the facility failed to ensure residents received their bath/shower per schedule for two (#3 and #7) of three sampled residents reviewed for bathing. The ADON identified 54 residents resided in the facility. Findings: The Hall Shower List Form, undated, documented all shower sheets must be filled out and returned to the nurse. It documented all refusals should be brought to the charge nurse to be charted, all showers as well needed to be charted in the electronic record. It documented all showers and refusals would be monitored daily by management. 1. Resident #3 had diagnoses which included cerebral palsy and glaucoma. Resident #3's Care Plan, revised 03/27/23, documented the resident required extensive assistance by staff for bathing. A Quarterly Resident Assessment, dated 09/17/23, documented Resident #3's cognition was intact, and they required extensive two person physical assist for bed mobility and transfers. It documented the task of bathing did not occur and/or non-facility staff provided care 100 percent of the time for the activity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 oberservation, record review, and interview the facility failed to ensure: a. proper storage and labeling for food-handling practices; and b. ice and coffee machines were in sanitary conditions with accordance to professional standards for food safety and service. Findings: On 10/11/22 at 11:33a.m., during the brief initial tour of the kitchen it was found that multiple food items were stored in refrigerator unlabeled and undated. The senior cook was asked about the unlabeled and undated items. They replied, This food was supposed to be thrown away and it never was tossed out. On 10/12/22 at 10:23a.m., the Dietary Manager was asked about the policy regarding these unlabeled items. They replied, They are supposed to be labeled and dated/or thrown away. The facility policies, read in part, .b. Educate and Inform i Educate staff, family, residents, visitors and community groups on resident's right to consume food foods not procured by the facility on admission, readmission and as needed. Education on safe food handling will be provided to all staff, family, residents,…

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

Based on record review and interview, it was determined the facility failed to ensure background checks were conducted for one (CNA#1) of five sampled employees reviewed for background checks. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility. Findings: The Abuse Protection policy, revised 05/03/22, read in part .Screening-Protocols for conducting employment background checks; background checks include State Criminal, Federal Criminal (if applicable), reference checks .Sex Offender check, and any other review required under State or Federal regulation . On 10/13/22 at 10:15 a.m., the HR director was asked to provide a copy of an OK SCREEN for CNA #1. The HR director stated that CNA #1 did not have one in their file and they had not seen them on OK Screen when they checked. On 10/13/222 at 10:50 a.m., the HR director provided a copy of an OK SCREEN for CNA #1. The OK Screen, dated 10/13/22, documented the screening had been conducted on 10/13/22 at 10:43 a.m. On 10/13/22 at 11:16 a.m., the HR director stated their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a dependent resident was bathed as scheduled for one (#22) of one sampled resident reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility and eight residents were dependent for bathing. Findings: Resident #22 admitted on [DATE] with diagnoses which included Alzheimer's disease. ADL bathing records and skin worksheets, reviewed from 08/19/22 through 08/31/22, documented Resident #22 had not been provided bathing two out of four opportunities. A resident assessment, dated 09/01/22, documented Resident #22 required total assistance for bathing. ADL bathing records and skin worksheets, reviewed from 09/01/22 through 09/30/22, documented Resident #22 had not been bathed five out of nine opportunities, and two out of three opportunities in October, 2022. ADL bathing records and skin worksheets, reviewed from 10/01/22 through 10/12/22, documented Resident #22 had not…

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

Based on record review and interview, the facility failed to ensure physician's orders were followed to obtain weights three times weekly for one (#31) of one sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility. Findings: Resident #31 had diagnoses which included heart failure and chronic kidney disease. A physician's order, dated 03/21/22, documented to weigh the resident three times weekly and notify the physician if there was a 3 pound gain each time or a five pound gain in a week. An August 2022 treatment sheet documented the resident had not been weighed nine out of 13 opportunities. A September 2022 treatment sheet documented the resident had not been weighed six out of 13 opportunities. An October 2022 treatment sheet documented the resident had not been weighed four out of five opportunities. On 10/13/22 at 11:07 a.m., the DON was asked what the policy was for obtaining resident weights. She stated monthly unless otherwise ordered. She was shown the above…

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

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5 percent. The medication error rate was 7.41 percent. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility. Findings: A medication administration policy, 2021 edition, documented medications are administered in accordance with written orders of the attending physician. Resident #17 had diagnoses which included personal history of transient ischemic attack (TIA), cerebral infarction, and constipation. A physician's order, dated, 10/06/22, documented to administer MiraLax packet 17 grams, 1 packet by mouth two times a day. A physician's order, dated, 10/11/22, documented to administer Children's aspirin tablet chewable 81 mg one tablet by mouth one time a day. An October 2022 MAR, documented aspirin and MiraLax had not been administered on 10/12/22. It documented to see the nurse notes. On 10/12/22 at 8:06 a.m., CMA #1 informed Resident #17 that their aspirin and Miralax were unavailable. A Note Text…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication carts were secured for one of one treatment/medication cart observed unlocked. The Resident Census and Conditions of Residents report, dated 10/11/22, documented 66 residents resided in the facility. Findings: A medication storage policy, 2021 edition, documented medication supply is accessible only to the license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. It documented medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. On 10/11/22 at 11:43 a.m., the hall 200 treatment/medication cart was observed to be unlocked and unattended. There were IV medications, FSBS supplies, ointments, and numerous creams and paste in the cart. On 10/11/22 at 11:47 a.m., LPN #1 approached the treatment/medication cart and locked it. When LPN #1 was asked what the policy for ensuring medications and treatments were secured, they stated, by locking the cart. When asked if the cart was locked when they…

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

Based on oberservation and interview, the facility failed to maintain mechanical and electrical equipment in safe operating condition. Findings: The maintenance supervisor and dietary manager opened the vents to the exhaust fans to witness the electrical equipment that were not in working condition. On 10/12/22 at 10:28 a.m., the dietary manager was asked about the exhaust fans. They stated, Our exhaust fans are not working right now and it was reported to the maintanence supervisior. We have maintanence fans on the kitchen floor and they do have lint on the fan blades.