Northbrooke Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview the facility failed to obtain physician orders, failed to ensure the physician orders were being followed, and failed to accurately care plan for 3 of 4 (Residents #29, #36, #478) sampled residents reviewed for respiratory therapy. The findings include: 1. Review of the facility policy titled Oxygen Administration, dated 4/2/2007, revealed .to provide guidelines for safe oxygen administration .Verify that there is a physician's order .Adjust the oxygen device so the proper flow of oxygen is being administered . Review of the facility policy titled Medication and Treatment Orders, dated 7/2016, revealed .Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state . 2. Review of the medical record revealed Resident # 29 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure, Diabetes, Heart Failure, and Depression. 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.

Based on review of the facility's Licensure Staffing Requirements, daily staffing schedules, and interview, the facility failed to ensure a Registered Nurse (RN D and MDS Coordinator) was on duty at least 8 hours a day, 7 days a week, for 2 of 28 days reviewed. The findings include: 1. Review of the facility's Nursing Home Daily Staffing schedules for March 2025 and April 2025 revealed no RN on duty for 8 consecutive hours on 3/16/2025 and 4/6/2025. 2. Review of the facility's daily working schedule for March 2025 and April 2025 confirmed no RN on duty for 8 consecutive hours on 3/16/2025 and 4/6/2025. 3. During an interview on 4/16/2025 at 11:47 AM, the Staffing Coordinator, was asked how many consecutive RN hours a day are required. The Staffing Coordinator stated, Eight. Then The Staffing Coordinator was shown the facility's NURSING HOME LICENSING CHECKLIST, dated 3/15/2025 - 3/28/2025 and 3/29/2025 -4/11/2025. The staffing Coordinator was asked about the 3/16 with 6.5 RN hours, Staffing Coordinator stated, [Named RN D] must have left early that day and [MDS Coordinator] must…

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 policy review, daily staff posting review, and interview, the facility failed to post the total number of staff, and actual hours worked by the licensed staff responsible for resident care on the facility's Daily Staff Posting form for 31 of 31 sampled days. The findings include: 1. Review of the facility's Daily Staff Posting forms were not completed for 31 of the 31 days requested. 2. During an interview on 4/16/2025 at 12:05 PM, the Staffing Coordinator was asked where the staff postings were located. The Staff Coordinator stated, We have them on the computer, I don't post them or print them for this company .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident Rights, medical record review, and interview, the facility failed to maintain accurate medical records related to Cardiopulmonary Resuscitation (CPR) for 1 of 1 (Resident # 378) sampled residents reviewed for CPR. The findings included: 1. Review of the undated .Resident [NAME] of Rights revealed It is designed to ensure residents receive care that respects their dignity, privacy and autonomy .Each resident shall have the right to .the resident's wishes and preferences must be considered in the exercise of rights . 2. Review of the medical record review revealed Resident #378 was admitted to the facility on [DATE], with diagnoses including Acute Respiratory Failure with Hypoxia, Pulmonary Disease, Congestive Heart Failure, Chronic Kidney Disease, and Diabetes. Review of the .Physicians Order for Scope of Treatment (POST) form dated [DATE], revealed Resident #378 was to have full treatment CPR. Review of the Care Plan dated [DATE], revealed Resident #378 has a terminal diagnosis receiving…

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 the CDC's [Center for Disease Control] Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings review, policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 79 occupied rooms contained a blood-tinged gauze, when 1 of 1 staff members (Certified Nurse Assistant (CNA) L) failed to properly store soiled linens, and when 5 of 5 staff members (Registered Nurse (RN) D and RN I, Licensed Practical Nurse (LPN A), CNA B and CNA L) failed to wear Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Contact Precautions, when 1 of 6 staff members ( LPN K failed to properly disinfect reusable medical equipment, when 1 of 6 staff members (LPN H) failed to properly store an enteral syringe, and when 3 of 3 staff members (LPN C, LPN H, and RN I) failed to perform hand hygiene. The findings include: 1. Review of the CDC's Core Infection Prevention and Control…

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 policy review, medical record review, observation, and interview, the facility failed to ensure staff was following physician orders for a Percutaneous Gastrostomy (PEG) tube feeding and failed to date and label PEG tube feedings for 2 of 2 (Resident #43 and #73) sampled residents reviewed for enteral feedings. The findings include: 1. Review of the facility's policy titled Tube Feeding Management/Restore Eating Skills dated 5/26/2023, revealed .Feeding tube care and services shall be provided in accordance with resident needs and professional standards of practice .Continuous feedings is the uninterrupted administration of enteral formula over brief extended periods of time .Gastrostomy tube is a tube that is placed directly into the stomach through the abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy [PEG] tube .Document the formula, rate, med flushes, auto flushes, and how administered . 2. Review of the medical…

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 policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by carbon build-up on the cooking stove, unlabeled and undated food items, and expired food items. The facility had a census of 88 with 84 of those residents receiving a tray from the Kitchen. The findings include: 1. Review of the Dietary: Food Storage, revealed .To provide guidance on how food is to be stored .All store items should have an expiration date .A 'Use-By' date is the last date recommended for the use of the product while at peak quality . ' Open Date ' -refrigerated .food .prepared and packaged .shall be clearly marked at the time the original container is opened . 2. Observation in the Kitchen on 5/21/2024 at 11:46 AM, revealed an opened, undated package of tater tots, undated hamburger patties and undated hashbrowns. 3. Observation in the Kitchen on 5/22/2024 at 4:14 PM, revealed the cooking stove burners had a black-build-up on the right…

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 policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 3 of 13 staff members (Certified Nurse Aide (CNA) A and B and Licensed Practical Nurse (LPN) C ) failed to perform proper hand hygiene during meal service and the facility failed to ensure precautions were followed to prevent spread of infections, failed to handle and store linens to prevent the spread of infection, and failed to ensure hygiene procedures were followed by staff when 4 of 4 staff members (Housekeeper D, Certified Nurse Assistant (CNA) A, and Licensed Practical Nurse (LPN) E and O) did not wear personal protective equipment (PPE) in a resident's room, when CNA A placed a dirty incontinent brief and a dirty incontinent pad on the resident's floor, and when CNA A and LPN E failed to perform hand hygiene. The findings include: 1. Review of the facility's policy titled, Hand Hygiene, dated 3/28/2024 revealed .Staff involved in direct resident contact shall perform proper hand hygiene procedures to prevent the spread of infection .Hand hygiene is…

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 policy review, observation, and interview, the facility failed to ensure staff maintained residents' dignity and respect when 2 of 13 staff members (Certified Nursing Assistant (CNA) A and CNA B) failed to knock and announce themselves before entering a resident's room during dining and during a random observation. The findings include: Review of the facility's Promoting/Maintaining Resident Dignity Policy, dated 11/20/2023 revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Explain .before initiating the activity .Respect the resident's living space . Observation during the Hall 200 dining on 5/20/2024 at 11:30 AM, revealed CNA A entered Resident #14's room and failed to knock or announce themself before entering resident's room. Observation during the Hall 200 dining on 5/20/2024 at 11:33 AM, revealed CNA A entered Resident #71's room and failed to knock or announce themself before entering the resident's room. Observation during the Hall 200 dining on 5/20/2024 at 11:38 AM, revealed CNA A…

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

Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 10 of 59 resident rooms (Resident #7, #12, #26, #28, #41, #43, #51, #52, #66, #189). The findings include: 1. Review of the facility's policy titled Resident Rights and Resident Responsibilities, dated 11/20/2023, revealed .The resident has the right to a safe, clean, comfortable Homelike environment . 2. Observation in the resident's room on 5/20/2024 at 8:14 AM, revealed Resident #12's room had a strong urine odor, dirty gloves, and towels on the floor in the bathroom. 3. Observation in the resident's room on 5/20/2024 at 8:16 AM, revealed Resident #26's bathroom had an odor of urine and urine in toilet, dried brown liquid substance on the toilet seat, and a bath basin in the bathroom with a brush and several unlabeled supplies in it. 4. Observation in the resident's room on 5/20/2024 at 8:21 AM, revealed Resident #51's wall beside the bed had been scraped and had white dust and debris on the floor, the bathroom floor revealed 2 unlabeled…

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 policy review, medical record review, review of the ADL (Activities of Daily Living) Verification Worksheets, Night shift shower assignment sheet, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance related to bathing and showering was provided for 3 of 20 (Resident #31, #35 and #74) sampled residents reviewed for ADL care. The findings include: 1. Review of the facility policy titled, Activities of Daily Living (ADL), dated 4/17/2024, revealed, .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good .grooming and personal and oral hygiene . Review of the facility undated policy titled, AHC Resident Rights and Responsibilities, revealed, .Respect and dignity, recognizing each resident's individuality, wishes and preferences . 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE], with diagnoses of Hemiplegia, Cerebral Infarction, Ataxia, Epilepsy, Depression,…

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 policy review, medical record review, observation, and interview the facility failed to provide necessary treatment and services to promote the healing of a pressure ulcer wound for 2 of 4 sampled residents (Resident #73 and #189) reviewed for pressure ulcers. The facility failed to provide ordered wound care and failed to ensure a pressure reducing mattress was properly implemented. The findings include: 1. Review of the facility's policy titled, Pressure Injury Prevention and Non-Pressure Ulcer Management dated February 26, 2024, revealed .It is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure ulcers/injury present, and to promote wound healing of various types of wounds in accordance with current standards of practice and Physician orders .Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence .A pressure injury will present as intact skin or an…

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

Based on policy review, observations and interviews, the facility failed to ensure all licensed nurses independently demonstrated competency while providing care and services for 2 of 6 Nurses (Licensed Practical Nurse (LPN) L and LPN O) observed. The findings include: Review of the facility's policy titled Medication Administration dated 8/4/2023, revealed .Medications shall be administered by licensed .nursing personnel acting within the scope of practice . Review of the facility's policy titled Tube Feeding Management/Restore Eating Skills dated 5/26/2023, revealed Purpose .To ensure that staff providing care and services to the resident via [by] feeding tube are aware of, competent in and utilize facility protocols regarding .care. Observation during Medication Administration on 5/21/2024 at 7:25 AM, revealed LPN L had cleaned the glucometer by wiping it 1 time with a Sani wipe and set it on the medication cart when another nurse that identified herself as a Regional Nurse (Assistant Director of Nursing) coached LPN L by telling her to wipe the meter 3 times with the Sani cloth…

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 policy review, observation, and interview, the facility failed to store all drugs and biologicals in locked compartments when a medication cart was left unlocked and unattended for 1 of 7 medication storage areas (Medication Cart 1) and when medications were left at the resident's bedside for 1 of 23 sampled resident's rooms (Resident #19). The findings include: 1. Review of the facility ' s policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, dated 9/5/2023, revealed .It is the policy of this facility to ensure all medications housed on our premises shall be stored in the pharmacy and/or medication rooms .All drugs and biologicals shall be stored in locked compartments .Only authorized personnel shall have access .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . 2. Observation in Resident #19's room on 5/20/2024 at 8:48 AM, revealed Latanoprost Ophthalmic eye drops (used to treat high…

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 policy review, medical record review, and interview, the facility failed to ensure the completion of a discharge summary with a recapitulation of the resident's stay, and failed to provide discharge instructions and reconciliation of medications to the residents' representatives on discharge from the facility for 3 of 3 sampled residents (Resident #84, #85, and #285) reviewed for discharge. The findings include: Review of the facility's policy titled, Transfer and Discharge, revised 11/2021, revealed .refers to movement of a resident .or other location in the community .when return .is not expected .orientation .discharge must be provided and documented to ensure a safe .discharge from the facility .member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete . Review of the medical record, revealed Resident #84 was admitted to the facility on [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment and failed to ensure fall risk assessments were completed for 6 of 6 sampled residents (Resident #18, #28, #74, #184, #185, and #186) reviewed for accident hazards and falls. The findings include: Review of the facility's policy titled, Accidents and Supervision, dated 10/21/2021, revealed .The resident environment remains as free of accident hazards .and each resident receives adequate supervision .This includes .identifying hazard(s) and risk(s) .evaluating and analyzing hazard(s) and risk(s) .implementing interventions to reduce hazard(s) and risk(s) . Review of the facility's policy titled, Occurrence Reporting, dated 12/2021, revealed .The facility will complete an Nurse Event note to document the details of an accident/incident/occurrence/unusual event effecting the resident using the Event process .A Nurse Event Note is an assessment that is completed to record the details…

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 the Centers for Disease Control and Prevention (CDC) guidelines, Employee Time Punch Reports, Employee Screening Logs, and interview, the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of COVID-19 when 27 of 106 staff members (Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14, Registered Nurse (RN) #1, and Licensed Practical Nurse (LPN) #3, #4, #5, #6, #7 #8, #9, #10, #11, #12, #13, and #14) failed to complete screenings for the prevention and detection of COVID-19 prior to work for 16 of 17 days (3/19/2022, 3/20/2022, 3/22/2022, 3/23/2022, 3/24/2022, 3/25/2022, 3/26/2022, 3/27/2022, 3/28/2022, 3/29/2022, 3/30/2022, 3/31/2022, 4/1/2022, 4/2/2022, 4/3/2022, and 4/4/2022) reviewed. The facility had a census of 89. The findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated…

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 policy review, medical record review, and interview, the facility failed to notify the Responsible Party for 1 of 5 sampled residents (Resident #28) reviewed for accidents hazards. The findings include: Review of the facility's policy titled, Notification of Change, dated 4/30/2021, revealed .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include .accidents . Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of Psychotic Disorder with Delusions, Dementia with Behavioral Disturbance, Restlessness, and Agitation. Review of Resident #28's Nursing Progress Note dated 3/13/2022, revealed .Was notified by CNA [Certified Nursing Assistant] that resident drunk [drank] peri wash .Assistant Director of Nursing was notified . During an interview on 4/5/2022 at 3:55 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview, the facility failed to ensure the care plan was implemented and followed for fall interventions for 1 of 1 sampled resident (Resident #184) reviewed for falls. The findings include: Review of the medical record, revealed Resident #184 was admitted to the facility on [DATE] with diagnoses of Fracture of Left Femur, Artificial Hip Joint, Muscle Weakness, and Need Assistance with Personal Care. Review of the Care Plan dated 3/21/2022, revealed Resident #184 was assessed for being at risk for falls with an intervention to place call bell/light within easy reach. Review of the admission Minimum Data Set (MDS) dated [DATE], indicated Resident #184 had a Brief Interview Mental Status of 5, which indicated she was severely cognitively impaired. Observation in the resident's room on 4/4/2022 at 9:30 AM, and at 3:12 PM, revealed Resident #184 in bed with the call light clipped behind her head on the pillow out of the resident's reach. Observation in 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 policy review, medical record review, observation, and interview, the facility failed to follow the facility's policy for monitoring weights for 1 of 5 sampled residents (Resident #67) reviewed for nutrition. The findings include: Review of the facility's policy titled, Dietary: Weight Monitoring, revised 11/9/2021, revealed .the facility will ensure that all residents maintain acceptable parameters of nutritional status .Weight can be a useful indicator of nutritional status .a weight monitoring schedule will be developed upon admission .Newly admitted residents .monitor weight weekly for 4 weeks .Residents with weight loss .monitor weight weekly until stable . Review of medical record, revealed Resident #67 was admitted to the facility on [DATE] with the diagnoses of Protein Calorie Malnutrition, Heart Failure, Diabetes, and Pressure Ulcer Sacral Region. Review of Resident #67's Malnutrition Risk assessment dated [DATE], revealed .Resident at risk for malnutrition .severe Protein Calorie Malnutrition…

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 policy review, medical record review, observation, and interview, the facility failed to follow the physician orders to monitor the oxygen flow rate for 1 of 4 residents (Resident #23) reviewed for respiratory services. The findings include: Review of the facility's policy titled, Oxygen Concentrator and Oxygen Storage, revised 12/2021, revealed .To administer oxygen for the treatment .in a safe manner .physician's orders for the rate of flow .on to the desired flow rate . Review of the medical record, revealed Resident #23 was admitted to the facility on [DATE] with the diagnoses of Chronic Obstructive Pulmonary Disease, Shortness of Breath, and Malignant Neoplasm of Upper Lobe Secondary to the Bone. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 required the use of oxygen. Review of a Physician's Order dated 2/1/2022, revealed .Oxygen (O2) at 2L/min [liters per minute] per nasal cannula [tube inserted into the nose with prongs to deliver oxygen] .O2 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 policy review, observation, and interview, the facility failed to ensure medications were securely locked, stored, and inaccessible to residents, unauthorized staff, and visitors when 2 of 9 medication storage areas (300 Hall Medication Cart and Treatment Cart) were found unlocked and unattended. The findings include: Review of the facility's policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/Emergency Box and Backup Pharmacy, dated 9/20/2021, revealed .All drugs and biologicals will be stored in locked compartments ( .medication carts, cabinets, drawers, refrigerators, medication rooms) .only authorized personnel will have access to the keys to locked compartments . Observation at the 300 Hall Medication Cart on 4/5/2022 at 2:55 PM, revealed an unlocked and unsecured medication cart. During an interview on 4/5/2022 at 3:02 PM, Licensed Practical Nurse (LPN) #9 confirmed that the medication cart should not have been left unlocked or unattended. Observation of the Treatment Cart on the Short Stay Unit Hall on 4/8/2022 at 8:01 AM,…

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.