Oak Park Nursing And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interviews, and record review, the facility did not ensure Minimum Data Set (MDS) assessment information accurately reflected resident's status for 3 residents (R) of 19 sampled residents (R8, R23, R37) and 1 supplemental resident (R48).R8's, R23's, R37's, and R48's MDS (Minimum Data Set) assessments have conflicting data and are inaccurate as section C indicates they are rarely or never understood, while section B indicates they are understood, have clear speech, and make themselves understood by others.R48's MDS indicates she discharged with return anticipated and that she had a fall with major injury. R48's emergency department notes indicate she had a fall with fracture. Her reentry assessment indicates she did not have a fall with major injury.Evidenced by:The facility did not provide a policy related to the completion of resident MDS.Example 1R8 admitted to the facility on [DATE] Type 2 diabetes, hypothyroidism (a condition in which the thyroid gland does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 4 (R82, R51, R3 and R1) of 19 sampled residents and residents eating in 1 of 3 dining rooms (10 residents out of a census of 68). R82 and R51 voiced concerns with hot foods not being hot. R3 and R1 voiced concerns regarding food temperatures. Surveyor conducted 1 test tray for the dining room which was not palatable. Evidenced by: Example 1 On 8/20/25 at 2:38 PM, Surveyor interviewed R82 during the initial screening process. During the interview R82 was asked if there were any concerns with meals. R82 indicated about 5 times a week the food is dry, tasteless, has no spices and the hot foods are not hot. Example 2 On 8/21/25 at 9:16 AM, Surveyor interviewed R51 during the initial screening process. During the interview R51 was asked if there were any concerns with meals. R51 indicated that about 5…

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 did not ensure that residents were ensured a dignified existence and self-determination for 2 of 17 sampled residents (R45 and R37). R45 voiced concerns that his catheter bag was not covered, including when he went to the dining room for meals. R37's wheelchair was observed to be dirty and undignified. As evidenced by: The facility policy titled, Resident Rights, dated 2001, states, in part: .Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. to be treated with respect, kindness, and dignity. e. self-determination. h. be supported by the facility in exercising his or her rights. The facility policy titled, Dignity, dated 2001, states, in part: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction 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 interview and record review the facility did not document a thorough investigation and did not resolve grievances as outlined in the facility policy for 1 of 1 Residents (R2) reviewed for grievances. R2 had voiced a concern to a staff member and the facility failed to follow their grievance policy by thoroughly investigating, following up, and documenting the concern.Evidenced by: The facility policy, Grievances/Complaints, Recording and Investigating indicates, in part: Policy Statement: All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Policy Interpretation and Implementation: 1. The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. 2. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations.4. The investigation and report will include, as applicable: a. the date and time of the alleged…

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 did not ensure that all alleged violations involving misappropriation of resident funds/personal property are reported immediately to the administrator of the facility, the State agency, and to other officials, including local law enforcement, in accordance with State law through established procedures for 1 of 22 sampled residents (R48) reviewed for abuse. The facility did not report allegations of abuse to the state agency in accordance with facility policy and federal regulations for an incident involving R48.Evidenced by:Facility policy, titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 9/2022, includes, in part: All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If…

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 did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment, that all alleged violations are thoroughly investigated and residents are protected pending a thorough investigation for 1 of 22 residents reviewed (R48). The facility did not thoroughly investigate R48's allegations of abuse by a staff member. The facility did not remove the alleged staff from patient care to protect residents while conducting a thorough investigation.Evidenced by:Facility policy, titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 9/2022, includes, in part: All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Upon receiving any allegations of abuse, neglect,…

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 did not provide the proper discharge documentation for 3 of 4 residents reviewed for discharge (R2, R5, and R73). R2 was transferred to the hospital, and no bed hold notice was provided. R5 was not provided a bed hold. R73 was transferred to the hospital, and no bed hold notice was provided. Evidenced by: The facility policy, Bed-Holds and Returns includes, in part: Policy Statement: Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation and Implementation: All residents/representatives are provided written information regarding the facility and state bed-hold policies, which addresses holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Resident's, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b.…

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 did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 sampled resident (R1) reviewed for dialysis.The facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis fistula site.This is evidenced by:The facility's policy titled Hemodialysis Catheters - Access and Care Of, dated 2001, with a Revision Date of February 2023, states, in part: . Care of Arterio-venous fistula (AVF)s. 4. To prevent infection and/or clotting: a. Keep the access site clean at all times. d. Check for signs of infection (Warmth, redness, tenderness or edema) at the access site when performing routine…

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 did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors in 28 opportunities that affected 2 out of 6 residents (R53 & R16) included in the medication pass task, which resulted in an error rate of 7.14%. R53 received Lasix (Furosemide) 10 mg tablet outside of the medication administration window. R16 received Metoprolol Extended Release (ER) 25 mg tablet that had been crushed. Evidenced by: The facility policy entitled, Administering Medications, dated 2001, states, in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered withing one (1) hour of their prescribed time, unless otherwise specified. Example 1 R53 was admitted to the facility on [DATE] and has diagnoses that include, 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 observation, interview, and record review, the facility did not ensure residents are free of significant medication errors, for 1 of 6 residents reviewed in the medication administration task (R16).R16 received a Metoprolol Succinate Extended Release (ER) 25 mg tablet (a medication used to treat high blood pressure and chest pain) that had been crushed.This is evidenced by:The facility policy, Adverse Consequences and Medication Errors, revised in February 2023, states in part, .Medication Errors - 1. A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include: .h. Failure to follow manufacturer's instructions and/or accepted professional standards (e.g.crushing a medication on the 'do not crush list' without an order).R16 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure drugs and biologicals are stored in accordance with currently accepted professional standards for 1 of 2 medication rooms reviewed for medication storage. The medication room on the first floor contained an expired single-dose COVID vaccine and 4 urinary catheter kits that were expired. This is evidenced by: Facility policy entitled, Medication Labeling and Storage with a revision date of February 2023 states, in part. Medication Storage.3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. On [DATE] at 10:36 AM, Surveyor conducted medication storage observation of the medication room on the first floor with RN P (Registered Nurse). Surveyor found a Spikevax single-dose COVID vaccine in the medication room refrigerator with an expiration date of [DATE] and 4 urinary catheter insertion tray kits in…

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

Based on observation, interview, and record review, the facility did not ensure snacks were offered at bedtime daily when there is more than 14 hours between the evening meal and breakfast for 1 resident (R3) of total census of 68 reviewed for snacks.R3 voiced concerns of snacks not being offered at bedtime.The facility is not offering all residents nourishing snacks at bedtime when their supper meal and breakfast meal are more than 14 hours apart.Evidenced by:Facility policy, titled Frequency of Meals, dated 2001, states, in part: . Policy Interpretation and Implementation: 1. The facility will serve at least three (3) meals or their equivalent daily at scheduled times. There will not be more than a fourteen (14) hour span between the evening meal and breakfast. 5. Nourishing snacks will be available for the residents who need or desire additional food between meals. 6. Evening snacks will be offered routinely to all residents. 7. Residents will also be offered nourishing snacks if the time span between the evening meal and the next day's breakfast exceeds fourteen (14)…

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 did not ensure the resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunization; and (B) That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal. This affected 1 of 5 residents (R33) reviewed for immunizations.R33 signed a consent form to receive the 2024-2025 influenza vaccine but never received it.This is evidenced by:The facility policy entitled Influenza Vaccine, with a revision date of March 2022, states in part: Policy Statement: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccines against…

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 has not established 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 Resident (R1) of 6 observed for Enhanced Barrier Precautions (EBP) and 1 (R1) of 8 opportunities for hand hygiene. Staff did not apply PPE (Personal Protective Equipment) appropriately while completing a treatment to R1 who was on EBP. Staff did not perform hand hygiene for appropriate amount of time during treatment. The facility policy entitled Handwashing/Hand Hygiene, dated October 2023, states, in part: . Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation Administrative Practices to Promote Hand Hygiene: 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing 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 did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 1 of 16 residents reviewed for homelike environment out of a total sample of 17 residents (R31). R31 voiced concerns related to the cleanliness of her room. Evidenced by: Resident Handbook, revised 6/8/08, includes: the facilities housekeeping staff will clean and mop resident rooms daily or more often as needed to ensure a clean, safe, and home-like environment. The facility reserves the right to clean any area or room and to remove items that prevent us safe and sanitary environment. Periodically the housekeeping department will do seasonal cleaning and floor care in resident rooms . Facility policy, entitled, Facility Resident Room Cleaning Procedure, undated, includes Wipe down with Fuzion: telephone, bedside tables, doorknobs, light switches, call…

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 did not develop a comprehensive person-centered care plan for 2 of 5 residents (R9 and R42) reviewed for unnecessary medications. The facility did not develop a care plan for R9 and R42's use of Melatonin (a medication used to help with sleep) for insomnia. This is evidenced by: The facility policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, states in part: .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident .Care plan interventions are chosen only after careful data gathering, proper sequencing of events,…

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 did not ensure residents received the necessary treatment and services consistent with professional standards of practice for 2 (R7 and R12) of 5 residents reviewed with non-pressure injuries. *R7 had non-pressure injuries to the left distal shin, the left dorsal foot, and the left calf. The wounds were not comprehensively assessed weekly and the facility documentation for the location and etiology of the non-pressure injuries were not consistent with the Wound Physician. * R12 developed a non-pressure injury to the right buttock on 7/8/2024 that was not comprehensively assessed until 7/12/2024 when R12 was seen by the Wound Physician. Findings include: The facility policy and procedure entitled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 3/2014 documents: Assessment and Recognition: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores, for example…

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 did not ensure residents received the necessary treatment and services consistent with professional standards of practice for 2 (R7 and R12) of 3 residents reviewed with pressure injuries. *R7 had a Stage 4 pressure injury to the left heel, a Stage 4 pressure injury to the left lateral foot, and a Stage 3 pressure injury to the left first toe. The wounds were not comprehensively assessed weekly and the facility documentation for the staging of the pressure injuries were not consistent with the staging by the Wound Physician. *R12 developed a Stage 2 pressure injury to the sacrum on 5/24/2024 that was not comprehensively assessed until 5/31/2024 when R12 was seen by the Wound Physician. The facility documentation for the wound indicated the wound was moisture associated skin damage (MASD) and did not correlate with the Wound Physician documenting the etiology of the wound being pressure. The pressure injury was not comprehensively assessed weekly.…

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 did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents (R5) reviewed out of a sample of 17 residents. R5 was assessed to be at risk for falls with care plan interventions of a low bed and fall mat while in bed. The facility did not ensure interventions were in place when R5 was in bed. Evidenced by: The facility policy, titled Assessing Falls and Their Causes, dated March 2018, states in part: .4. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly .the following information should be recorded in the resident's medical record: .6. Appropriate interventions take to prevent future falls. The facility policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, states in part: A comprehensive, person-centered care plan that includes, measurable objectives and timetables to meet 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 interview and record review the facility did not ensure that residents that use psychotropic drugs have appropriate assessments, diagnoses, and consent. This affected 2 of 5 residents (R9 and R42) reviewed for unnecessary medications. R9 receives an antipsychotic for dementia. R42 receives an antipsychotic for anxiety. R42 is receiving an antidepressant and does not have active consent. This is evidenced by: The facility policy, titled Psychotropic Medication Use dated July 2022, states in part: Residents will not receive medications that are not clinically indicated to treat a specific condition .Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. anti-psychotics; b. anti-depressants; c. anti-anxiety medications; and d. hypnotics .are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed…

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 did not ensure residents are free of significant medication errors for 1 of 1 resident's reviewed for significant medication errors (R1). On 3/4/24, the facility received orders for R1 to receive Humalog sliding scale insulin. This order did not specify the frequency of administration. Two Registered Nurses (RN's) signed off on the order, but did not clarify how frequently the insulin was to be administered. Facility staff entered to administer the Humalog four times daily on R1's Medication Administration Record (MAR) without a clarification order from R1's physician. Additionally, R1 did not receive the Humalog insulin as ordered on 3/4/24, 3/5/24, 3/6/24, and 3/7/24. This is evidenced by: R1 was admitted on [DATE] with diagnoses including, but not limited to: diabetes mellitus type 2, morbid obesity, polymyalgia rheumatica (inflammatory disorder that primarily affects the shoulders and hips), major depressive disorder, anxiety, and asthma. R1's February…

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 did not ensure that all alleged violation involving neglect are reported immediately to the State Survey Agency for 1 resident (R1) of 3 reviewed of a total sample of 6 residents. The facility failed to immediately report an allegation of neglect to the State Survey Agency. This is evidenced by: The facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation-Reporting and Investigating, with a revision date of 9/22, states, in part: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly investigate an allegation of neglect for 1 (R1) of 3 sampled Residents. The facility failed to complete a thorough investigation into R1 allegation. This is evidenced by: The facility policy titled, Identifying Types of Abuse, with a revision date of 9/22, states, in part: . 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. a. Abuse also includes the deprivation by an individual, including a caretaker, or goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . The facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation-Reporting and Investigating, with a revision date of 9/22, states, in part: 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine 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, the facility did not ensure the provision of pharmaceutical services including administering of all drugs and biologicals to meet the needs of each resident for 2 out of 3 sampled residents (R1 and R4). R1 did not receive his medications in a timely manner, resulting in several medication errors. R4 did not receive her medications in a timely manner, resulting in several medication errors. This is evidenced by: The facility policy titled Administering Medications last revised April 2019, states in part .4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan .7. Medications are administered…

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 and interview, the facility did not ensure each resident has a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 4 (R57, R10, R17, and R27) of 25 residents R10 and R27 voiced concerns with the cleanliness of bedrooms. Surveyor observed concerns with cleanliness for R57, R10, R17, and R27's bedrooms. Evidenced by: The facility did not provide a housekeeping policy. Example 1: R57 was admitted to the facility on [DATE] with diagnoses including: unspecified dementia without behavioral disturbance, cognitive communication deficit, difficulty in walking, kidney failure, anxiety disorder, and major depressive disorder. R57's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/29/23, indicates R57 has a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. R57 has an Activated Health Care Power of Attorney. On 4/11/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal hygiene for 5 of 19 residents (R25, R48, R57, R66, and R68) reviewed for ADLs. R66 had long facial hair and long toenails that are thick and discolored. R66 requires assistance with shaving and nailcare. R25 had long facial hair and requires assistance with ADLs. R48 was not provided assistance with eating and requires assistance. R68 had long nails and nail care had not been provided R57 Surveyor observed R57 not receive assistance with eating meals. Surveyor observed R57's fingernails long with a dark substance underneath fingernails. This is evidenced by: The Facility policy, Activities of Daily Living (ADL), Supporting, with a revised date of March 2018, states, in part: Policy Statement: .Residents who are unable to carry out activities of daily living independently will…

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 did not provide an ongoing, individualized, and meaningful program to support the residents in their choice of activities, which was designed to meet their interests and support their physical, mental, and psychosocial well-being. This affected 3 (R5, R10, and R57) of 19 sampled residents and 1 of 1 (R3) supplemental residents reviewed for activity participation. The facility failed to offer a variety of activities that meet the interests and support all residents' physical, mental, and psychosocial well-being. The facility failed to ensure resident's activity care plans were personalized to meet the needs of residents physical, mental, and psychosocial well-being. The facility failed to create personalized goals and develop a tracking/monitoring system for resident's activity attendance. Evidenced by: The facility policy titled Activity Programs with a revised date of June 2018, states, in part, Policy Statement Activity programs are designed to…

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

Based on interview and record review the facility did not assess a resident using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) not less frequently than once every 3 months for 1 of 19 sampled residents (R38). R38 did not have a quarterly Minimum Data Set (MDS) completed. This is evidenced by: Per R38's MDS record, she had assessments completed on the following dates: 3/11/22 Quarterly 6/11/22 Quarterly 8/30/22 Quarterly 11/30/22 Annual R38 was due for a Quarterly assessment end of February 2023 or beginning of March 2023. There were no completed or in progress assessments noted in R38's medical record. With R38's Quarterly assessment not being done, the facility could have missed critical indicators of gradual change in a resident's status. Due to R38's assessment not being completed the care plan was not reviewed either. On 4/13/23 at 9:14 AM, Surveyor interviewed RMDSC I (Regional MDS Coordinator). Surveyor asked RMDSC I what the process is for MDS completion; RMDSC I explained that herself and two 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.