Arlington Heights Health and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #3 did not physically abuse Resident #2. On 07/17/25, Residents #2 and #3 physically attacked each other and Resident #2 suffered scratches to her left cheek and lip. The noncompliance was identified as PNC. The noncompliance began on 07/17/25 and ended on 07/17/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for abuse. Findings included: Record review of Resident #2's Quarterly MDS Assessment, dated 07/23/25, reflected she was a [AGE] year-old female who was originally admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS (cognitive screening tool) score of 2. She was noted to have had physical behaviors directed towards others for 4 to 6 days. Her active diagnoses included non-Alzheimer's disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a care plan for Resident #1's Foley catheter. This failure placed resident at risk of not receiving appropriate care. Findings included:Record review of Resident #1's MDS dated [DATE] reflected the resident was [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE]. The MDS reflected Resident #1's cognition was intact with a BIMS score of 15, and his diagnoses included quadriplegia (a condition characterized by the loss of function or paralysis in all four limbs and sometimes the torso), neurogenic bladder (a dysfunction that results from interference with the normal nerve…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident who enters the facility with an indwelling catheter receives appropriate treatment and services for 1 of 3 (Resident #1) reviewed for catheters.The facility failed to obtain physician orders to address the treatment and services that were to be provided to care for Resident #1's Foley catheter.The failure placed residents at risk for catheter complications and infection. Findings included: Record review of Resident #1's MDS dated [DATE] reflected the resident was [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE]. The MDS reflected Resident #1's cognition was intact with a BIMS score of 15, and his diagnoses included quadriplegia (a condition characterized by the loss of function or paralysis in all four limbs and sometimes the torso), neurogenic bladder (a dysfunction that results from interference with the normal nerve pathways associated with urination), and Stage 2 pressure ulcer of the right buttock (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that an alleged violation involving abuse was reported immediately but not later than 2 hours after the allegation was made to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for abuse. LVN A failed to immediately report an abuse allegation to the Administrator, who was the facility's abuse coordinator, when she overheard CNA B verbally abusing Resident #1 in early May 2025. This failure could have caused residents to experience abuse by staff. Findings included: Record review of Resident #1's admission Record, dated 06/04/25, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 04/01/25, reflected she had a BIMS score of 06, which indicated severe cognitive impairment. Her active diagnoses included Non-Alzheimer's Dementia (a general decline in cognitive abilities that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were treated with respect, dignity, and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #5) reviewed for resident rights. The facility failed to treat Resident #5 with dignity when staff failed to assist the resident with colostomy care, resulting in it leaking and causing her to feel embarrassed in front of her roommate. This failure could cause the resident embarrassment and a decreased sense of self-worth. Findings included: Record review of Resident #5's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the rights side of her body, legal blindness, and rectal cancer requiring the creation of a colostomy (opening in the intestine to drain feces into a bag). Record review of Resident #5's quarterly MDS, dated [DATE] reflected a BIMS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #5) reviewed for ostomy care. The facility failed to assist Resident #5 with colostomy care resulting in her colostomy leaking. This failure could place the resident at risk of skin irritation and breakdown from exposure to fecal matter. Findings included: Record review of Resident #5's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting the rights side of her body, legal blindness, and rectal cancer requiring the creation of a colostomy (opeing in the intestines to allow feces to drain into a bag). Record review of Resident #5's quarterly MDS, dated [DATE] reflected a BIMS score of 10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and the PASARR evaluation report for 8 (Residents #2, #3, #15, #23, #29, #39, #62, #71) of 10 residents reviewed for PASARR assessments. The facility failed to submit a Nursing Facility Specialized Services (NFSS) form request by the specific deadline for Residents #2, #3, #15, #23, #29, #39, #62, and #71. This failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #2's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], reflected a BIMS of 06 indicating severe cognitive impairment. Resident #2 had diagnoses of anxiety disorder (significant 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, interview, record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 6 residents (Residents #13 and Resident #63) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #13's care plan was revised to include her pleasure feedings. 2. The facility failed to ensure Resident #63's care plan was revised to include his dialysis treatment. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. Findings included: 1. Record review of Resident #13's Face Sheet, dated 09/26/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #25) of five residents reviewed for ADL care. The facility failed to provide Resident #25 assistance with timely incontinence care. The failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection. Findings included: 1. Record review of Resident #25's face sheet, dated 09/26/24, indicated Resident #25 was a [AGE] year-old male, admitted to the facility on [DATE], and readmitted on [DATE]. Record review of Resident #25's admission MDS assessment, dated 09/05/24, revealed Resident #25's BIMS score was 11 indicating his cognition was moderately impaired. Resident #25 required substantial/maximal assistance with toileting. Resident #25 was dependent on staff for shower/bathing and personal hygiene.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 (Resident #81) of 2 residents reviewed for intravenous fluids. The facility failed to ensure Resident #81's intravenous medication bag and tubing were labeled with the date, time, and initials. The facility failed to ensure Resident #81 received timely PICC line (used to deliver medications and other treatments directly to the large central veins near heart) dressing change. Resident #81 went without a dressing change for 8 days. The failures could affect residents by placing them at risk for infections and cross-contamination and at risk for medication error, and delay in medication administration. Findings included: Review of Resident #81's entry MDS assessment, dated 09/24/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses including which included: Pneumonia, (lung infection that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on 1 of 4 medication carts (100 Hall medication aide cart) and 2 of 2 residents (Residents#36 and #57) reviewed for pharmacy services. The facility failed to ensure the 100 Hall medication aide medication cart contained accurate narcotic logs for Residents #36 and #57. These failures could place residents at risk for medication error, drug diversion, and delay in medication administration. Findings included: 1. Review of Resident# 36's Quarterly MDS Assessment, dated 08/08/24, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included encounter for palliative care. The resident had severe impaired cognition with a BIMS score of 3. She received scheduled pain medication regimen. 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 observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 doorway in the south hallway of Zone 3 in between the vending machines and the doorway to the smoking courtyard reviewed for accidents and hazards. The facility failed to ensure residents who accessed the south hallway of Zone 3 in between the vending machines and the doorway to the smoking courtyard was free of hazards, when a large puddle of water was observed on July 5, 2024. The facility failed to ensure the south hallway of Zone 3 in between the vending machines and the doorway to the smoking courtyard was free of slip/fall hazards. Findings included: Observation on 07/05/2024 at 12:07 PM of the south hallway of Zone 3 between the vending machines and the door to the smoking courtyard revealed a large puddle of water that had entered from the gaps in the doorway and missing threshold during a brief rain shower approximately 20 minutes prior. Four residents had to be cautioned about the water on the floor while…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of four residents observed for infection control. The facility failed to prevent Resident #1's indwelling urinary Foley catheter device from contact with the floor. This failure could place the residents at risk of cross-contamination and development of infection. Findings included: Review of Resident #1's Face Sheet, dated 06/07/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. One of his diagnoses was obstructive and reflux uropathy (a condition where urine cannot flow because of blockage in the urinary tract). Review of Resident #1's Quarterly MDS Assessment, dated 05/04/2024, reflected Resident #1 had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plans for 3 (Residents #1, #2, and #3) of 5 residents reviewed for comprehensive care plans in that: The MDS Coordinators failed to individualize the care plans, to include interventions, for Residents #1, #2, and #3. This failure could place the residents at risk of receiving the individualized care they required. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg. morbid obesity, heart failure, and asthma. Review of Resident #1's admission MDS assessment, dated 01/04/24, revealed a BIMS score of 10 indicating she had mild cognitive impairment. Her Functional Status indicated she required assistance with most of her ADLs. Review of Resident #1's care plan, dated 01/01/24 revealed her care plan had not been individualized. Resident #1 has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living, receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #1) of 3 residents reviewed for ADLs. The facility failed to ensure Resident #1 was not left in a soiled brief for an extended period of time on 04/04/24. This failure could place the resident at risk for skin breakdown. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg, morbid obesity, heart failure, and asthma. Review of Resident #1's admission MDS assessment, dated 01/04/24, revealed a BIMS score of 10 indicating she was mildly cognitively impaired. Her Functional Status indicated she required assistance with most of her ADLs, and assistance of 1-2 people for toileting. Her Bowel and Bladder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and assure only authorized personnel had access to the keys for 1 (Resident #2) of 1 resident reviewed for pharmacy services, in that: The facility failed to ensure that Resident #2's albuterol inhaler, one bottle of levocetirizine (allergy medication) 5 mg, eleven pills Slow Fe (iron) tablets, and two yeast plus tablets were stored in a secured place. This failure could place all residents on the 300 Hall North at risk of drug diversion or misuse of medications. Findings included: Record review of Resident #2's face sheet, dated 01/17/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: allergic rhinitis (inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mold, or flakes of skin from certain animals), acute respiratory failure (serious condition that makes it difficult to breathe), and asthma (narrow 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, interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for one (Resident #3) of five resident rooms reviewed for accidents and hazards. The facility failed to ensure the closet doors in Resident #3's room were maintained in a safe and functional manner. This failure could place residents at risk of accidents or injury. Findings included: Record review of Resident #3's face sheet dated 01/17/24 indicated the resident was a [AGE] year-old male, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included weakness, reduced mobility, contracture (shortening of muscles) unspecified joint, contracture unspecified knee, muscle weakness, history of falling, age related nuclear cataract, bilateral (major cause of blindness), epilepsy (nerve cell activity in the brain is disturbed causing seizures). Record review of Resident #3's MDS assessment dated [DATE] indicated Resident #3 had moderately impaired cognition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #1) of 3 residents reviewed for accurate medical records in that: LVN A failed to complete the initial admission assessment documentation on Resident #1 when she admitted to the facility on [DATE]. LVN A failed to document on the MAR/TAR indicating what medication Resident #1 admitted with and whether any of the medications were administered during Resident #1's short stay in the facility. This deficient practice could result in misinformation about professional care provided. Findings included: Record review of Resident #1's electronic face sheet dated 10/21/23 reflected the resident was admitted to the facility on [DATE]. Her diagnoses included: unspecified fracture of shaft of humerus (the bone of the upper arm) and arm, diabetes (group of diseases that affect how the body uses blood sugar) and fracture of the nasal bone. Record review of Resident #1's chart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for and pharmacy services. 1. The facility failed to follow physician orders and provide Resident #1's treatment to her newly amputated leg sutures and incision site on 12/25/23, 12/27/23, 01/01/24 and 01/03/24. 2. The facility failed to follow physician orders and provide Resident #2 her analgesic topical pain medications of Diclofenac Sodium External Gel on 01/05/23 and a Lidocaine Patch on 01/02/24, 01/03/24 and 01/05/23. The failure could place residents at risk for increased pain, infection and physical discomfort. Findings included: 1. Record review of Resident #1's Face Sheet dated 12/27/23 reflected she was a [AGE] year old female who 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 observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for one (Resident #1) of three reviewed for quality of care. The facility failed to maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for Residents #1. The failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #1's Face Sheet dated 12/27/23 reflected she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included atherosclerosis (thickening and hardening of the arteries) of native arteries of left leg with ulceration (a long-lasting (chronic) sore that takes more than 2 weeks to heal) of other part of foot, paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, maintained medical records on each resident that were complate and accurately documented for one (Resident #1) of four residents reviewed for quality of care. The facility failed to provide wound care to Resident #1's coccyx on 12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24 and document when it was provided. The facility failure placed residents at risk of continued pain, discomfort, infection and a worsening of their wounds. Findings included: Record review of Resident #1's Face Sheet dated 12/27/23 reflected she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses which included atherosclerosis (thickening and hardening of the arteries) of native arteries of left leg with ulceration (a long-lasting (chronic) sore that takes more than 2 weeks to heal) of other part of foot, paroxysmal atrial fibrillation (occurs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for eight (Rooms #302, #303, #305, #306, #307, #308, #309) of ten rooms reviewed for infection control. CNA A failed to use hand hygiene while passing lunch trays on the 300 hall Rooms #302, #303, #305, #306, #307, #308, #309. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Observation on 10/20/23 at 11:45 AM-12:08 PM of CNA A on hall 300, was observation of the food cart that was pushed to the floor (hall), and CNA A approached the food cart and proceeded down the hall (300). CNA A did not use hand hygiene prior to touching the food cart, prior to touching food trays, or while passing out lunch trays to residents on 300 hall. CNA A approached 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 interview and record review, it was determined the facility failed to inform the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for one (Resident #1) of one resident reviewed. The facility failed to notify Resident #1's state mental health agency or intellectual disability agency of a significant change for Resident #1 when he expired on [DATE]. This failure could affect residents in the facility that are PASRR positive for their mental health agency or state intellectual disability agency not being notified of a significant change for residents. Findings included: Review of Residents #1's discharged face sheet, dated [DATE], reflected the resident admitted to the facility on [DATE] and discharged from the facility on [DATE]. His diagnoses included acute respiratory failure with hypoxia (below normal level of oxygen in the blood),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs for 6 (Residents #8, #10, #34, #38, #40, and #76) of 8 residents reviewed for PASARR compliance. The facility failed to follow up on Residents #8, #10, #34, #38, #40, and #76, who were PASARR Level I positive and refer them to the local authority for further evaluation to determine their need for specialized services. This failure placed the residents at risk of not receiving the full extent of services available to them and/or alternative living accommodations. Findings included: Record review of residents triggered for PASARR review revealed six residents had not been referred to the local authority for PASARR II screening or had form 1012 filed verifying they had dementia…

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, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #82) of 18 residents reviewed for quality of care. The facility failed to ensure Resident #82 received dressing changes to his lower legs as scheduled. This failure placed the resident at risk of infection and decreased feelings of self-worth. Findings included: Review of Resident #82's admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included skin infection to both lower legs, heart failure, and reduced mobility. Review of Resident # 82's admission MDS, dated [DATE], revealed a BIMS score of 13 indicating he was cognitively intact. His Functional Status indicated he required limited assistance with his ADLs. Review of Resident #82's care plan, dated 07/17/23, revealed he had edema, putting him at risk for fluid imbalance; venous ulcers to both lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status based on the residents' comprehensive assessments for 4 (Residents #90, #91, #204, and #206) of 18 residents reviewed for nutrition. The facility failed to obtain Resident #90, #91, #204, #206 weights at admission per facility policy. This failure placed the resident at risk of infection and decreased feelings of self-worth. Findings included: Review of Resident #90's admission Record, dated 08/22/23, revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidney disease), and high blood pressure Review of Resident # 90's quarterly MDS, dated [DATE], revealed a BIMS score of 14 indicating the resident was cognitively intact. Review of Resident #90's care plan, dated 04/09/023, revealed Resident #90 had a potential risk of malnutrition, had an altered diet, renal regular diet. The 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, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition for 2 (Residents #37 and #81) of 18 residents reviewed for ADL's. 1. The facility failed to ensure Resident #37 was getting assistance with feeding. 2. The facility failed to ensure Resident #81 was bathed as scheduled. This failure had the potential to affect residents by placing them at risk for poor nutrition and a decline in their quality of life. Findings included: Review of Resident #37's MDS dated [DATE] revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, Alzheimer's disease, glaucoma, and dysphagia. Resident #37 had severely impaired cognition rarely/never understood others and never/rarely made self-understood. The MDS further revealed Resident #37 required extensive assistance of one person for eating. Review of 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, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders and the comprehenxive person-centered care plan for 1 (Resident #97) of 1 resident reviewed for parenteral fluids. The facility failed to ensure Resident #97's PICC line dressing remained intact. This failure placed the resident at risk of infection. Findings included: Review of Resident #97's admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of bone infection of the right foot and ankle with right 4th toe amputation. Review of Resident #97's admission MDS, dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. His Functional Status indicated he required limited assistance with his ADLs. Review of Resident #97's care plan revealed he had a surgical site to his right foot requiring wound care and dressing changes; IV access…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for one (Resident #37) of five residents reviewed for therapeutic diets. The facility failed to provide Resident #37 a pureed diet as prescribed by the physician. The failure placed residents at risk for aspiration and weight loss. Findings included: Review of Resident #37's MDS dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, Alzheimer's disease, glaucoma, and dysphagia. Resident #37 had severely impaired cognition rarely/never understood others and never/rarely made self-understood. Review of Resident #37's physicians order summary report for August 2023 revealed she was on a regular diet, puree texture with a start date of 05/15/23. Review of Resident #37's hospital records dated 05/12/23 revealed the following: Speech-Language…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 3 (rooms [ROOM NUMBER]) of 10 rooms observed. The facility failed to maintain rooms [ROOM NUMBER] in a safe and sanitary condition. This failure could place residents at risk for decreased quality of life. Findings included: Observation on 08/03/23 during the following hours revealed: 9:45 AM - room [ROOM NUMBER] - The window screen was bent at the bottom and detached from the window leaving a gap between the window and the screen. 10:01 AM - room [ROOM NUMBER] - There were three ceiling tiles that were slightly bulging out and had water stains on them right above the window. The window screen was bent at the bottom leaving a gap between the screen and the window. 10:01 AM - room [ROOM NUMBER] - The bottom half of the window screen was ripped. Interview on 08/03/23 at 12:04 PM with the Maintenance Director revealed he was aware of the ripped and dented screens. He…

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.