Oak Park Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 13 residents (Resident #81) reviewed for care planning. The facility failed to ensure Resident #81's comprehensive care plan accurately reflected the required safety interventions for smoking.This failure could result in residents not receiving the level of intended care. Findings included:Record review of Resident #81's admission Record reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included schizoaffective disorder (a disorder in which a person has difficulty distinguishing reality from hallucinations or delusions). Record review of Resident #81's annual MDS submitted 12/12/2025 reflected a BIMS of 00, which indicated severely impaired cognition. Record review of Resident #81's Smoking Safety Screen dated 2/19/2026 reflected the following:1. notes on safety from IDTC (i.e. resources required to support resident, other…

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 the resident has a right to be treated with respect and dignity for 1 of 8 (Resident #74) residents reviewed for grooming in that: Resident #74 had facial hair on upper lip and chin. This failure could place residents with unwanted facial hair at risk of low self-esteem. The Findings:Record review of Resident #74's admission Record dated 3/13/2026 revealed she was admitted on [DATE], age of 58, and was diagnosed with nicotine dependence, lack of coordination, auditory hallucinations and major depressive disorder. Record review of Resident #74's admission MDS dated [DATE] was documented as impaired vision, usually understood, had a BIMs score of 7/15 (severely cognitively impaired), had hallucinations, she mobilized with a manual wheelchair, and required partial/moderate assistance with personal hygiene (the ability to maintain personal hygiene, including shaving). Record review of Resident #74's care plan dated 1/20/2026 revealed…

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 receives adequate supervision to prevent accidents for 1 of 13 residents (Resident #81) reviewed for accidents and hazards. The facility failed to ensure Resident #81 was supervised while smoking on 3/10/2026. This failure could result in injury. Findings included: Record review of Resident #81's admission Record reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included schizoaffective disorder (a disorder in which a person has difficulty distinguishing reality from hallucinations or delusions). Record review of Resident #81's annual MDS assessment submitted 12/12/2025 reflected a BIMS of 00, which indicated severely impaired cognition. Record review of Resident #81's Care Plan Report printed 3/10/2026 reflected the following:[Resident #81] is a smoker. Unsafe to smoke. May smoke WITH SUPERVISON [sic] and smoking apron in place. Has been educated on facility smoking policy. 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 observation, interview, and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 8 residents (Resident #4) reviewed for medically related social services. The facility failed to ensure Resident #4 was assisted in obtaining psychology/psychiatry consultation as ordered by physician on 1/29/2026 and developing interventions that are targeted and meaningful to the resident.This failure could place residents who have a mental illness diagnoses at risk of not receiving needed mental and psychosocial counseling services.Findings included: Record review of Resident #4's admission record dated 3/13/2026, reflected that she was [AGE] years old, initial admission was on 8/27/2025 and she re-admitted on [DATE]. The resident was diagnosed with diabetes mellitus (condition that occurs when the body cannot properly use blood sugar), anxiety (a feeling of worry, nervousness,…

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 assist residents in obtaining routine and 24-hour emergency dental services to meet the needs of 1 of 8 (Resident #12) residents reviewed for dental services. The facility failed to ensure Resident #12 received dental services when she had a broken tooth that caused her discomfort. This failure could place residents at risk of not receiving needed dental care and a decreased quality of life.The findings included: Record review of Resident #12's admission record, dated 03/10/2026, reflected Resident #12 was an [AGE] year-old female who initially admitted [DATE] and re-admitted [DATE], with diagnoses to include dementia (the loss of cognitive functioning that interferes with daily life and activities), major depressive disorder, and dysphagia (difficulty in swallowing). Record review of Resident #12's quarterly MDS assessment, dated 01/24/2026, reflected Resident #12 had a BIMS score of 15 out of 15, indicating intact cognition. The 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 observation, interview, and record review, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 21 meals on the Week 4 menu reviewed food and nutrition services. This facility failed to ensure the residents , who consumed this meal, received a balanced dinner meal that included a protein, in accordance with established national guidelines, on Tuesday 03/10/2026 (Day 24 of the Week 4 menu). This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake, weakness, and weight loss. The findings include:Record review of the facility's Dinner on Tuesday (Day 24 of the Week 4 menu) reflected: homemade vegetable soup, house salad with dressing, crackers, and chocolate chip cookie. 1.Record review of Resident #7's admission Record dated 03/13/2026 was documented she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 1 of 6 residents (Resident #76) reviewed for infection control. The facility failed to ensure CNA C performed hand hygiene while providing incontinence care to Resident #76.This failure could lead to infection or illness. Findings included: Record review of Resident #76's admission Record dated 3/13/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included dementia (a progressive disorder characterized by memory and cognitive decline). Record review of Resident #76's annual MDS submitted 1/7/2026 reflected a BIMS score of 15, which indicated intact cognition. Record review of Resident #76's Care Plan Report printed 3/13/2026 revealed Resident #76 required staff assistance for all…

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 provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 3 of 4 resident hallways (Hallway 100/300/400) reviewed for physical environment. 1. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a yellow stain around the toilet bowl with missing caulking 2. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a black stain mark on the lower bathroom door measuring 2x1 ft. 3. The facility failed to ensure resident room [ROOM NUMBER] located on hallway 300 had repaired a chipped piece of bathroom tile which measured approximately 2x2 inches and a broken piece of floor molding which measured approximately 2x2 inches on the right side wall adjacent to the bathroom. 4. The facility failed to ensure resident room [ROOM NUMBER] located on hallway 300 had repaired a missing section of the lower door jam on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 7 Residents (Resident #1) whose records were reviewed for care plans. The facility failed to ensure Resident #1's care plan was revised to reflect the use of oxygen. This deficient practice could place Residents at risk of not receiving the care and services they needed.Findings included: Record review of Resident # 1's face sheet, dated 11/5/25 revealed a 74 - year old male admitted on [DATE] with diagnosis included : Unspecified Dementia (a condition where the cause of cognitive decline is unknown), respiratory failure with hypoxia (a condition where the body does not receive enough oxygen), and general anxiety disorder (a mental health condition marked by persistent worry about everyday life events) Record review of Resident # 1's quarterly MDS, dated [DATE], revealed a BIMS score of 2 which indicated a severe cognitive deficit. Record review of Resident #1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 4 dining rooms (Station 4 dining room) observed for resident rights. The facility failed to ensure CNA W and CNA X were not using their personal phones while in the dining room, sitting with residents on 12/18/24. This failure could place residents at risk of not being treated with dignity and respect. Findings included: Record review of Resident #62's admission Record, dated 12/16/2024, reflected Resident #62 was initially admitted on [DATE] and readmitted on [DATE]. Resident #62 was noted to be [AGE] years old. Resident #62 was diagnosed with mononeuropathy (damage that happens to a single nerve which can cause pain, loss of movement and/or numbness). Record review of Resident #62's Annual MDS assessment, dated 09/30/2024, reflected Resident #62 had a BIMS of 15, indicating intact cognition. Interview and observation on 12/18/24 at 12:26 PM revealed CNA W and CNA…

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 received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 3 of 30 residents (Resident #22, Resident #31, and Resident #53) reviewed for quality of care. 1. The facility failed to ensure Resident #22's Humalog KwikPen insulin (a lightweight pen that is prefilled with insulin, a hormone that helps the body use glucose for energy) was given per physician order. 2. The facility failed to ensure Resident #31's HgA1c lab (a blood test that measure the average blood sugar level of the past 3 months) was drawn every 3 months as per physician order. 3. The facility failed to ensure Resident #53's Midodrine HCl (a medication used to treat low blood pressure) was given per physician order. These failures could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health. Findings included: 1. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate identifying accessory and cautionary labeling instructions, and 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 3 of 30 residents (Residents #37, #22, and #53) reviewed for pharmaceutical services, in that: 1. The Hall 100 Nurse's cart contained a Glargine Kwik Pen for Resident #37 which was marked with an open date of 11/3/2024, making it past 28 days from its open date, meaning it was expired. 2. The facility failed to ensure Resident #22's Humalog KwikPen insulin (a lightweight pen that is prefilled with insulin, a hormone that helps the body use glucose for energy) was given per physician order. 3. The facility failed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 2 of 4 medication carts (Hall 100 Nurse's and Medication Aide carts) reviewed for medication labeling and storage, in that: 1. The Hall 100 Nurse's cart contained a plastic bag which contained (3) opened and used Lispro insulin Kwik Pens for Resident #29, but only one of the Lispro Kwik Pens had an open date, resulting in no way for the Nurse to tell how long the other (2) pens had been opened, and if they were past their expiration dates. 2. The Hall 100 Medication Aide's cart contained (2) loose pills in single separate blister packs on the bottom of the 3rd drawer of the medication cart, with no pharmacy label on the pills with the resident's name and any cautionary information. These failures could place residents at risk of receiving expired…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. In a refrigerator, there were foods that were not labeled with the name of the food product and discard dates. 2. In the walk-in refrigerator, there were food products that needed to be discarded as it was past their use-by dates. 3. Dietary Aide T and [NAME] U had nose rings while handling food. 4. In the food preparation area, there were personal beverages and outside food in a to-go container. 5. Dietary Aide V documented the refrigerator temperature was 42*F on 12/01/2024. Dietary Aide V did not assess what could have caused this temperature reading, which was the kitchen's protocol. 6. Dusty debris was on the chains above the food preparation area that held cooking ware. These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness. The findings were: 1. Interview and observations of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #62) reviewed for clinical records. 1. The facility failed to ensure LPN J accurately documented on Resident #62's MAR (Medication Administration Record) when on 12/02/2024 she held the physician ordered Losartan Potassium (a blood pressure medication) because the resident's blood pressure was outside the approved range. 2. The facility failed to obtain signed consents for antipsychotic medications for Resident #73 who was administered Risperdal Oral Tablet 0.5 MG (Risperidone) related to bipolar disorder). (Risperidone is an atypical antipsychotic used to treat schizophrenia and bipolar disorder) and required a written signature on Form 3713, Nursing Facility Consent for Antipsychotic or Neuroleptic 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.

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 to help prevent the development and transmission of communicable diseases and infections for 4 of 12 residents (Residents #74, #20, #40 and #54) reviewed for infection control in that: 1. The facility failed to ensure CNA-Q followed proper infection control practices by not changing gloves and sanitizing hands after touching privacy curtain to pull it around the bed, then proceeding with catheter and peri-care with Resident #74. 2. The facility failed to ensure CNA-P followed proper infection control practices while emptying the colostomy bag for Resident #20 by not changing her gloves after emptying the colostomy bag into a basin, and before touching the bathroom door handle and shower handle when taking the basin to the bathroom to empty and rinse the basin. 3. The facility failed to ensure LVN-N washed or sanitize her…

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

Based on interview and record review, the facility failed to provide notice to residents of the change as soon as was reasonably possible when changes in coverage were made to items and services covered by the Medicare and/or Medicaid state plan for 2 of 3 residents [Resident #95, Resident #001] reviewed for Medicaid and Medicare Coverage Liability Notices. The facility failed to ensure Resident # 95 and Resident #001 were provided a Skilled Nursing Facility Advance Beneficiary Notice of non-coverage Form CMS-10055 [SNF ABN] that informs a Medicare beneficiary that Medicare will no longer pay for skilled services when discharged from skilled services at the facility prior to completion of covered stay or covered days being exhausted when he/she was discharged from Medicare Part A skilled nursing services. This failure placed residents, or their representatives, at risk for not being fully informed about services covered by Medicare Part A and not being aware of changes to provided services. Findings included: Record review of the facility Beneficiary Notice Worksheet (undated)…

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 the comprehensive assessment accurately reflected the resident's status for 2 (Resident #26 and Resident #49) of 3 residents reviewed for accuracy of assessments. 1. The facility failed to accurately code Resident #26's smoking status on his modified significant change comprehensive assessment. 2. The facility failed to accurately code Resident #49's smoking status on his significant change comprehensive assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #26's admission Record, dated 12/18/2024, reflected Resident #26 was admitted on [DATE]. Resident #26 was noted to be [AGE] years old. Record review of Resident #26's Diagnosis Report, undated, reflected Resident #26 was diagnosed with right knee effusion (excess fluid accumulates in and around the right knee, can result 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 interview and record review, the facility failed to develop a baseline care plan including the minimum healthcare information necessary to properly care for the resident within 48 hours of the resident's admission, for 1 (Resident #30) of 30 residents reviewed, in that: Resident #30's baseline care plan was not completed within 48 hours of the resident's admission on [DATE]. This failure could place newly admitted residents at risks of not receiving the proper care and continuity of services. The findings were: Record review of Resident #30's face sheet, dated 12/19/2024, revealed she was an [AGE] year-old woman admitted to the facility on [DATE] with diagnoses which included: Chronic Kidney Disease-Stage 3; Type 2 Diabetes Mellitus (chronic condition where the body has trouble controlling blood sugar); Dementia (a general term for loss of memory, and other cognitive abilities) ; Schizophrenia (mental illness that affects how a person thinks, feels and behaves); Bipolar Disorder (a disorder associated…

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 seen by a physician at least once every 30 days for the first 90 days after admission for 1 of 2 residents (Resident #13) reviewed for physician services. The facility failed to ensure Resident #13 was seen by a physician within the first 30 days of his admission to the facility. This failure could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status. The findings included: Record review of Resident #13's admission Record, dated 12/16/2024, reflected Resident #13 was admitted on [DATE]. Resident #13 was noted to be [AGE] years old. Record review of Resident #13's Diagnosis Report, undated, accessed 12/19/2024, reflected Resident #13 was diagnosed with quadriplegia (paralysis of all four limbs), polyneuropathy (a disorder that damages the peripheral nerves, which control the movement of the arms and legs), and hypertensive heart disease (heart problems…

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' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and the physician documented what, if any, action has been taken to address them, for 1 of 6 residents (Residents #2) whose records were reviewed for pharmacy services. After 11/18/24 medication review for Resident #2, the facility failed to add a doctor's order as was recommended by the pharmacist and approved by MD D. This failure could place residents at risk for significant health status declines. The findings included: Record review of Resident #2's admission record, dated 12/19/24, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnosis to include type 2 diabetes, hypertension (high blood pressure), chronic kidney disease. Record review of Resident #2's quarterly MDS Assessment, dated 12/06/24, reflected Resident #2 had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Record…

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 labratory services were provided to meet the needs of the resident in accordance with professional standards of practice, and for 1 of 30 residents (Resident #31) reviewed for labratory service. The facility failed to ensure Resident #31's HgA1c lab (a blood test that measure the average blood sugar level of the past 3 months) was drawn every 3 months as per physician order. These failures could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health. Findings included: Record review of Resident #31's face sheet dated 12/18/2024, revealed she was a [AGE] year-old woman initially admitted on [DATE] and re-admitted on [DATE], with diagnoses which included: cerebral infarction (stroke), quadriplegia (paralysis which affects all 4 limbs), and type 1 diabetes mellitus without complications (lifelong condition where the pancreas makes little or no insulin, leading to high blood sugar…

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 follow menus for 1 of 1 resident meals (dinner meal on 12/18/2024) reviewed for menus in that: The facility failed to follow the menu for residents on pureed diets for the dinner meal on 12/18/2024. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings included: Record review of Fall Winter Menu Week 4 2024-2025 for Wednesday (Day 25) Supper reflected Sloppy [NAME], Tater Tots, and Coleslaw. Record review of the pureed substitutes for Day 25 menu was Pureed Sloppy [NAME], Pureed Tater Tots, and Pureed Soft Cooked Vegetables. Record review of Pureed Tater Tots included ingredients Chicken Base, Water, and Tater Tots. Record review of Pureed Soft Cooked Vegetables included ingredients Soft, Cooked vegetable and Margarine, Solids. During an interview while [NAME] Y pureed food preparation for 12/18/24 dinner on 12/18/24 at 02:27…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 2 residents (Resident #22) reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included the current hospice plan of care to ensure Resident #22 received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Record review of Resident #22's admission Record, dated 12/18/2024, reflected Resident #22 was initially admitted on [DATE] and readmitted on [DATE]. Resident #22…

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 plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs for 1 of 6 residents (R# 1), reviewed for care plans. R#1's care plan did not contain measurable goals and objectives for alcohol use and abuse from, although the resident had five documented episodes of alcohol intoxication or smelled of alcohol. This non compliance was identified and corrected prior to entrance. This failure could place residents at risk for not receiving the care and treatments listed in the care plan and could lead to a diminished quality of life associated with alcohol use and abuse. The findings were: Record review of R #1's EMR and face sheet, dated 12/02/24, revealed an admission date of 3/14/23, re-admitted [DATE], discharged [DATE] with diagnoses that included: alcohol abuse with alcohol induced anxiety disorder, alcohol use, major depressive disorder, lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's EMR reflected accurate wound care documentation on 10/24/2024,10/26/2024,10/27/2024 and 10/31/2024. These deficient practices could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. Findings included: Record review of Resident #1's face sheet, computer dated 11/8/2024, revealed he was a [AGE] year old male with an initial admit date of 2/21/24 and readmitted on [DATE] with diagnoses which included cerebral vascular accident(cva-medical term for a stroke. When blood flow to a part of the brain is stopped.), left side affected, Diabetes Mellitus 2( the body has 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 observations, interviews and record reviews, the facility failed to provide reasonable accommodation of resident needs 2 of 10 resident rooms (Resident #328 and Resident #26) reviewed for call lights, in that: The facility failed to ensure Resident #328's and Resident #26's call light were within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention when needed. Findings included: 1. Record review of Resident #328's face sheet, dated 11/17/23, revealed the resident was originally admitted to the facility on [DATE] with diagnoses which included: dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities). Record review of Resident #328's MDS assessment, dated 11/07/23, revealed the resident's BIMS score was 12/15, which indicated moderate cognitive impairment. The resident needed help with self-care (bathing, dressing, eating, or using the toilet). Record review of Resident #328's care plan…

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 3 of 3 residents (Resident #29, Resident #40, Resident #79) reviewed for dialysis in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #29, #40, and #79. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of Resident #29's face sheet, dated 11/17/23 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with type 2 diabetes mellites, hyperlipidemia (elevated cholesterol), and Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (condition in which the kidneys cease functioning on a permanent basis).…

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

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 (lunch meal) observed for planned menus, in that: 1. The facility failed to ensure all residents received roasted red potatoes with their lunch meal on 11/14/2023. 2. The facility failed to ensure carrot cake was served with their lunch meal on 11/14/2023. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. The findings included: Record review of the facility's, Fall/Winter 2023, Week 1 Day 3, menu revealed Onion Sage Chicken, Roasted Red Potatoes, Spinach, and Carrot Cake w/Cream Cheese Frosting were to be served with the lunch meal on 11/14/2023. Record review of the November substitution log revealed that substitutions did not include mashed potatoes for roasted red potatoes and chocolate cake for carrot cake w/cream cheese frosting. 1. During an observation and interview on 11/14/23 at 12:47 PM in the 400-hall dining room, the LVN H revealed Resident #9 had a regular diet and had mashed potatoes instead…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, reviewed for kitchen sanitation, in that: 1. The facility failed to ensure dented cans were not in the dry storage room, on a rack: a. A pineapple tidbits can with a dent in the top corner of the can b. A Manwich original can with small dents in the can. 2. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 3. The facility failed to ensure that sanitizing buckets were not near containers of food. 4. The facility failed to ensure there were use-by dates in the freezers and refrigerators. 5. The facility failed to ensure a clear, plastic wrapped tuna sandwich, dated 11/12/23, was thrown away. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. During an observation and interview on 11/14/23 during the initial kitchen tour starting at 9:23 AM, a pineapple…

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 clinical records in accordance with accepted professional standards and practices that were accurately documented for 2 of 32 Residents (Resident #6 and Resident #79) reviewed for medical records, in that: 1. The facility failed to ensure Resident #6's medication administration was documented at the time it was administered. 2. The Facility failed to properly document Resident #79's return from dialysis assessment. This failures could place residents at risk for improper care due to inaccurate records. The findings were: 1. Record review of Resident #6's face sheet, dated 11/17/2023, revealed the resident was admitted [DATE] and readmitted on [DATE] with diagnoses that included: paraplegia, chronic pain, pressure ulcer of right buttock stage 2, pressure ulcer of left ankle stage 4, pressure ulcer of right hip stage 4, pressure ulcer of sacral region stage 4, and pressure ulcer of left hip stage 4. Record review of Resident #6's MDS assessment,…

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

Based on observation, interview, and record review, the facility failed to 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 disease and infection for 1 of 4 units (unit 400) reviewed for infection control, in that: 1. The biohazard room for Unit 400 was not kept locked. 2. Staff were not wearing droplet precautions PPE in hallway 200. These failures could place residents at-risk for infection due to improper care practices. The findings include: 1. Observation on 11/16/23 1:45 p.m. revealed the biohazard room on hall 400 was left open. The door had a keypad but the door was left unlocked. Closed boxes marked biohazard were seen in the room as well as closed trash barrels. On the outside of the door there were signs for biohazard and authorized staff only. Observation on 11/16/23 at 2:00 p.m. revealed multiple CNAs seen entering the biohazard room after keying the code on the keypad. This surveyor tried to open the door and the door was still…

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 be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 8 Residents (Resident #64) reviewed for the ability to call for staff, in that: The facility failed to ensure that Resident #64 had a functional call light system. This failure could place residents at risk for injury and diminished self-esteem, due to the inability to call for assistance. The findings included: A record review of Resident #64's electronic face sheet, dated 11/14/23, revealed an admission date of 4/28/23, re-admitted [DATE], with diagnoses which included difficulty in walking, lack of coordination, and mild cognitive impairment. A record review of Resident #64's care plan revealed focus of [Resident #64] is high risk for falls r/t mild cognitive impairment with intervention Be sure the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 4 units (unit 400) observed for environment, in that: 1. The facility failed to ensure potential hazards were locked up and kept out of resident rooms. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment. The findings included: Review of Resident #231's face sheet dated 11/17/2023, revealed an admission date of 11/02/2023 with diagnostics which included: Cerebral ischemia (Insufficient blood flow to the brain), Type 2 diabetes mellitus (high level of sugar in the blood) , Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Aphasia (difficulty with language), and Hypertension (High Blood pressure). Review of Resident #231's admission MDS assessment dated [DATE], revealed Resident #231 had memory problem and was severely impaired. She was non verbal. 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 observations, interviews and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 1 of 10 Resident's (Resident #16) reviewed for environment. The facility failed to ensure the broken and missing tiles in the restroom in Resident #16's bathroom was repaired. The facility failed to ensure that Resident #16's shower was clean. These failures could affect the residents and place them at risk for not having a safe and sanitary homelike environment. The findings included: Record review of Resident #16's face sheet, dated 11/14/23 revealed Resident #16 was originally admitted on [DATE] with diagnoses that included reduced mobility, difficulty in walking, muscle weakness, and direct infection of hand. Record review of Resident #16's most recent quarterly MDS assessment, dated 10/2/23, revealed the resident had a BIMS of 15/15 that indicated Resident #16 was cognitively intact. Record 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 interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 7 residents (Resident #38) whose assessments were reviewed, in that: Resident #38's quarterly MDS incorrectly documented the resident as receiving an anticoagulant medication. This failure could place residents at-risk for inadequate care due to an inaccurate assessments. The findings were: 1. Record review of Resident #38's face sheet, dated 11/15/2023, revealed an admission date of 07/08/2014 and, a readmission date of 05/08/2023 with diagnoses that included: Dementia(decline in cognitive abilities), Seizures (uncontrolled shaking movements), Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure) and, Malformation of coronary vessels (Heart artery is in the wrong spot or it…

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 the resident environment remained as free of accident hazards as was possible for 1 of 32 residents (Residents #59) reviewed for accidents and hazards in that: The facility failed to ensure Residents #59 did not have 3 disposable razors in his rooms. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: Record review of Resident #59's admission record dated 11/17/23, revealed diagnosis including cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, epilepsy, major depressive disorder, hemorrhagic disorder due to extrinsic circulating anticoagulants, and muscle weakness. Record review of Resident #59's MDS, dated [DATE], revealed the residents cognition was intact and the resident required limited assistance with personal hygiene. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 resident (Resident #63) reviewed for respiratory care. Facility failed to clean and replace the filter for Resident #63's oxygen concentrator. This deficient practice could affect residents who receive oxygen therapy which could contribute to respiratory infections. The findings were: Record review of Resident #63's face sheet, dated 11/14/2023, revealed Resident #63 was admitted on [DATE] with an original admission date of 02/08/2019 with diagnoses which included: chronic obstructive pulmonary disease with (acute) exacerbation, acute bronchitis, generalized anxiety, acute respiratory failure with hypoxia, personal history of other disease of the respiratory system and dependence on supplemental oxygen. Record review of Resident #63's Quarterly MDS, dated [DATE], revealed Resident #63's BIMS score was 15 with…

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

Based on observations, interviews and record reviews failed to accommodate residents' food preferences for 1 of 8 (Resident #11) residents reviewed for food preferences, in that: Resident #11's lunch meal tray on 11/14/23 did not follow her dislike of chocolate. This could affect all residents with food preferences and could result in a decrease in resident choices and diminished interest in meals. The Findings were: Record review and observation of Resident #11's 11/14/23 lunch meal revealed that Resident #11's tray ticket included a dislike of chocolate, but Resident #11 still received chocolate cake. During an observation and interview on 11/14/23 at 12:56 PM in the 300-hall dining room, the CMA J stated Resident #11's meal tray ticket said that Resident #11 disliked chocolate. CMA J revealed that Resident #11 received chocolate cake for 11/14/23 lunch. Resident #11 stated she did not like chocolate and was not going to eat the chocolate cake. During an interview on 11/14/23 at 1:40 PM, the DM stated Resident #11's 11/14/23 lunch meal tray ticket revealed that Resident #11 did…

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 provide pharmaceutical services to ensure accurate administration and documentation of medications for 2 of 12 residents (Residents #1 and #2) reviewed for pharmacy services and medication administration in that: The facility failed to administer medications as prescribed for Residents #1 and #2. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. The findings included: Record review of the admission face sheet, dated 11/9/2023, reflected Resident #1 was a female initially admitted on [DATE], readmitted [DATE], with a diagnosis included: hypertensive heart disease without heart failure (high blood pressure without affecting the pumping action of the heart muscles), atherosclerotic heart disease of native coronary artery without angina pectoris (the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall without chest pain), peripheral…

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 that all visitors enjoy full and equal visitation privileges consistent with resident preferences for 1 of 5 residents (Resident #1) reviewed for Visitation Rights, in that: The facility put stipulations on the form of Resident #1's visits with family members that went against the resident's choices. This deficient practice could place residents at risk for decreased quality of life, depression, and isolation. The findings were: Record review of Resident #1's face sheet, dated 10/30/2023, revealed the resident was admitted [DATE]. Resident #1's diagnoses included: major depressive disorder, schizophrenia, anxiety, and insomnia. Record review of Resident #1's Quarterly MDS Assessment, dated 9/11/2023, revealed Resident #1 had a BIMS of 15 which indicated Resident #1 was cognitively intact. Record review of Resident #1's care plan, with an effective date 8/30/2023, stated, (Resident #1) is independent in activities in room and out of room.…

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 develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 2 residents (Resident #3 and #7) reviewed for care plans. The facility failed to ensure proactive, measurable interventions were in place to address focus areas listed involving falls and other injuries for Residents #3 and #7. Different interventions were not identified after each fall to prevent future falls. This failure could place residents at risk for not receiving proper care and services due to inaccurate or incomplete care plan interventions. The findings included: Record review of Resident #3's face sheet, dated 10/17/23, reflected a [AGE] year-old female…

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 the resident(s) environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 16 residents (Resident #12) reviewed for accident hazards and supervision, in that; Resident #12 had one unauthorized, unchaperoned elopement events on 8/12/2023, without the facility providing adequate safety interventions to prevent further elopement risks. This failure placed residents at risk for harm, injury, or death due to elopement. The findings included: Record review of Resident #12's admission record, dated 10/17/2023, reflected a [AGE] year-old female with an admission date of 07/24/2023, and diagnoses which included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), unspecified dementia (decline in cognitive…

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