Lincoln Park Nursing and Rehab LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility did not ensure 1 (R1) of 5 Residents were provided with reasonable accommodations of Resident needs and preferences. *The Facility was aware of R1 having concerns regarding the shower room being too cold for R1 to take a shower, causing R1 to refuse showers. R1 was noted to have 1 documented bed bath in the last 30 days. R1 was not offered or given interventions to allow R1 to stay warm while taking a shower. Findings include: R1 was admitted to the facility on [DATE] with diagnoses which include: excoriation (skin picking disorder), stomatitis, heart failure, dependence on supplemental oxygen and anemia. R1's Annual Minimum Data Set (MDS), dated [DATE], documents R1 has adequate hearing, speech and is able to understand and be understood. R1 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 is cognitively intact. No behaviors exhibited. R1 expressed being able to choose between a tub bath, shower, bed bath or sponge bath, is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not report 1 (R4) of 2 incidents to the State survey agency and/or Nursing Home Administrator during the required timeframe. R4 voiced concerns of staff being rough with him. This allegation of mistreatment was not reported to the Nursing Home Administrator or State agency. Findings include: The facility's policy titled, Abuse, Neglect and Exploitation and reviewed/revised 1/5/24 documents under policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section VII Reporting/Response documents A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within…

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 2 of 2 allegation of abuse, neglect, exploitation or mistreatment involving R4, R9, & R10 were investigated or thoroughly investigated timely. * R4 allegation of staff being rough with him was not investigated. * R9 & R10 resident to resident altercation was not thoroughly investigated. Findings include: The facility's policy titled, Abuse, Neglect and Exploitation and reviewed/revised 1/5/24 documents under policy It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section V. Investigation of Alleged Abuse, Neglect and Exploitation documents A. An immediate investigation is warranted when allegation of suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for…

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 1 (R7) of 8 residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the residents choice. * On 3/3/25 R7 was not wearing tubigrips according to R7's physician orders and plan of care. Findings include: R7's diagnoses includes hemiplegia and hemiparesis following cerebral infarction, aphasia, vascular dementia, anxiety disorder, and paranoid schizophrenia. R7's actual ADL (activities daily living) self-care performance/mobility deficit care plan initiated documents an intervention * Dressing: Physical Assist of 1 -Tubigrips on in AM (morning) off HS (hour sleep) -Wears glasses. Initiated 9/9/22. R7's physician order dated 5/16/23 documents Tubigrips on in the AM and off at HS. In the morning for edema on and in the evening for edema off. R7's quarterly MDS (minimum data set) with an assessment reference date of 1/27/25 has a BIMS (brief interview mental status)…

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 1 (R2) of 1 Residents reviewed with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. *R2 was observed not wearing R2's right hand splints to prevent further decrease in range of motion. Findings Include: Surveyor reviewed the facility policy and procedure Range of Motion Exercises revised 10/2010 which documents: .Documentation The following information should be recorded in the Resident's medical record: 4. Whether the exercise was active or passive. 7. Any problems or complaints made by the Resident related to the procedure. 8. If the Resident refused the treatment, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. Reporting 1. Notify the supervisor refuses the exercises. 2. Report other information in accordance with facility policy and professional standards of practice. R2…

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 review the facility did not ensure 1 (R1) of 1 residents reviewed for colostomy, urostomy or ileostomy services, received care consistent with professional standards of practice. *R1 was not provided ostomy supplies and R1 ordered ostomy supplies from (community pharmacy name) & R1 was provided the incorrect ostomy supplies, per R1's order. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], documents R1 has verbal behaviors toward others 1 to 3 days, no rejection of care, is supervision or touch assistance with shower/bathing, frequently incontinent of bladder and has an ostomy device. R1 receives oxygen therapy. On 03/03/2025, at 09:35 AM, Surveyor interviewed R1. R1 indicated The Facility ran out of R1's ostomy supplies. R1 indicated that Staffing Coordinator/CNA-N indicated to R1 that the supplies were stolen. R1 indicated that R1 had to make an order for delivery from (community pharmacy name) for R1's ostomy supplies, and is waiting for 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.

Based on observation, interview and record review the facility did not ensure 1 of 4 residents observed during medication pass had appropriate dispensing of medication that did not break infection control practices. On 3/4/25 at 8:03 a.m. Surveyor observed Registered Nurse (RN)-H dispense R11's medications. RN-H touched each of the pills dispensed for R11 with bare hands. Findings include: The facility's Administering Medications policy with revised date of December 2024. The policy documents . 22. Staff shall follow established facility infection control procedures (e.g handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 3/4/25 at 8:03 a.m. Surveyor observed RN-H dispense R11's medications. Surveyor observed RN-H bare handed open over the counter medications and bare handed touch the medications and placed it in the medication cup. Surveyor observed RN-H pop out medications from the blister pack and into her bare hands then placed it in the medication cup. On 3/4/25 at 1:00 p.m. Surveyor interviewed NHA…

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 interviews, personnel file review, and review of the job description, the facility failed to ensure a qualified person was designated to serve as the Director of Food and Nutrition Services for 83 of 83 census residents. This failure had the potential to affect kitchen sanitation and resident quality of care related to food and nutrition. Findings include: Review of the personnel record for the Dietary Manager (DM) included no education related to food services. During an interview on 11/14/24 at 8:23 AM, the Dietary Manager (DM) said she has been in her position with the facility for about a year. She was not aware that she needed to be certified. She said nobody has ever asked her about her certification or informed her that she needed to have any certification. She knew it would be better to have but did not know she needed it. She said she will be taking an exam on Friday for the Managerial ServSafe certification. During an interview on 11/13/24 at 3:42 PM, the Administrator stated she was not sure about the DM's certification but stated she was enrolled and had 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 record review, interviews, and policy review, the facility failed to ensure four of four residents (Residents (R) 331, 11, 57, 18) and/or their power of attorney (POA) reviewed for hospitalization, received written notice of transfer. Findings include: Review of the facility's Transfer and Discharge Guideline policy, dated 11/28/17, revealed that for a transfer or discharge the facility will provide a written notice to the resident and resident representative in a manner and language in which is understood. 1. Review of R331's electronic medical record (EMR), under the Census tab revealed she was originally admitted to the facility on [DATE] with diagnosis that included Myasthenia Gravis, metabolic encephalopathy, cognitive communication deficit, generalized muscle weakness, dementia, type 2 diabetes mellitus, and morbid obesity due to excess calories. Review of R331's most recent quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 08/19/24 and located in the MDS tab…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to ensure four of four residents (Residents (R) 331, R11, R57, R18) and or their power of attorney (POA) reviewed for hospitalization received written notice of the bed hold policy upon transfer to the hospital. This failure had the potential to cause confusion or distress regarding return to the same room after hospitalization for 83 residents. Findings include: Review of the facility's Bed Hold and Return Guideline policy, dated 04/25/19, revealed, The facility will provide written information to the resident or resident representative before the resident is transferred to a hospital or the resident goes on therapeutic leave that specified the following: - The duration of the state bed-hold policy during which the resident is permitted to return and resume residence in the nursing facility. - The reserve bed payment policy in accordance to the state plan. - The facility's policies regarding bed-hold periods permitting resident to return…

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 facility policy review, the facility failed to ensure food prepared by the facility was served at a palatable temperature for five of six residents (Resident (R) 34, R285, R9, R64 and R54) reviewed for palatability of 33 sample residents. As a result of this deficient practice the residents had the potential for poor nutrition and weight loss. Findings include: 1. Review of R34's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/03/24, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident moderate cognitively impairment. During an interview on 11/11/24 at 11:00 AM R34 stated the food could be better and that it always arrived cold during all meals. 2. Review of R285's entry tracking MDS assessment with an ARD of 10/28/24, revealed no BIMS assessment was completed. During an interview on 11/11/24 at 11:12 AM R235 stated the food sucked. There was no variety or flavor, and they did not provide condiments. 3. Review of R9's quarterly MDS assessment with an ARD…

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, record review and policy review, the facility failed to ensure one of one resident (Resident (R)30) with medications at the bedside had been assessed and evaluated to self-administer medications. Findings include: Review of R30's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 10/01/24 with medical diagnoses that included acute respiratory failure. Review of R30's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/07/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R30 was cognitively intact. During an observation and interview on 11/11/24 at 2:00 PM, R30 was in bed and on the bedside table was a tissue box with a bottle of Fluticasone and saline nasal spray. The resident confirmed they were her meds, got them and kept saying they were over the counter, and she could have them. Review of R30's Orders tab in the EMR revealed there was no physician orders for the administration 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, record review and policy review the facility failed to ensure that residents are free from abuse from another resident for one of five residents (Resident (R) 25) reviewed for abuse out of a sample of 23. After R25 bumped into R66 with the wheelchair, R66 aggressively grabbed R25 arm causing an injury of bruising on the left arm of R25. Failure to protect residents from abuse has the potential to result in injury to residents. Findings include: Review of the facility's policy titled, Abuse/Neglect/Exploitation, with revision date 01/05/24, revealed, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Review of R25's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/21/21 and a readmission date of 06/24/24 with medical diagnoses that included vascular dementia. Review of…

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

Based on interview, record review, and facility policy review, the facility failed to report an allegation of resident-to-resident abuse to the state agency for two residents (Residents (R)52, R77) reviewed for abuse out of a sample size of 33. Findings include: Review of R77's admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 07/28/24 and located in the MDS tab of the electronic medical record (EMR), revealed he scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. He had no behaviors. Review of R52's admission MDS assessment, with an ARD of 08/27/24 and located in the MDS tab of the EMR, revealed she scored ten out of 15 on the BIMS, indicating moderately impaired cognition. She had no behaviors. Review of R54's quarterly MDS assessment, with an ARD of 08/20/24 and located in the MDS tab of the EMR, revealed she scored 13 out of 15 on the BIMS, indicated intact cognition. Review of R77's and R52's EMRs revealed no documentation of any allegation of resident-to-resident abuse. During an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to ensure the care plan included interventions for aggressive behavior, alcohol abuse with disruptive behaviors, and change of a urinary catheter from a Foley to a suprapubic urinary catheter for two of five residents (Resident (R)66 and R77) reviewed for abuse, one of three residents (R69) reviewed for urinary catheter care. As a result of this deficient practice the residents had the potential for lack of needed care and supervision. Findings include: 1. Review of R66's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 02/08/23 with a readmission on [DATE] with medical diagnoses that included unspecified dementia, mild with agitation. Review of R66's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R66…

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, record review, interview, and facility policy review, the facility failed to reconcile, transcribe, and administer medications to ensure medications were provided to residents as indicated or ordered for three residents reviewed (Resident (R) 12, R18, and R282) out of a sample of 33 residents. This failure had the potential to result in adverse health outcomes. Findings include: Review of the facility's Administering Medications policy, revised December 2012, revealed, The individual administering the medication must check the label three [3] times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 1. Review of the admission Record found under the profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with a diagnosis of heart failure, restless legs syndrome, chronic obstructive pulmonary disease. Review of R12's quarterly Minimum Data Set (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 interviews, record review, and interviews, the facility failed to provide care in accordance with physician orders and the plan of care for one (Resident (R) 76) out of six residents reviewed for care planning, out of 33 sampled residents. Specifically, the facility failed to perform wound care treatments as ordered. Findings include: A review of the facility's Grievance Log, from January of 2024 through 11/11/24, revealed a grievance filed by R76 on 10/26/24. Per the log, it was reported to a nurse that R76 was upset wound care was not complete this weekend. The log also indicated the Director of Nursing (DON) was assigned to investigate on 10/29/24 and concluded with Discipline given to [employee]. [Education] provided on unacceptable performance and [reiterated] expectation. Review of R76's Facesheet, provided by the facility, revealed the resident was admitted on [DATE] with a primary admission diagnosis of aftercare following a surgical amputation. Secondary diagnoses included heart failure, type 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure physician orders for oxygen administration were followed and ensure residents with continuous positive air pressure (CPAP) had physician orders to administer the CPAP treatment for two of three residents (Resident (R) 30 and R36) reviewed for respiratory therapy. As a result of this deficient practice the residents had the potential for harm due to inaccurate oxygen administration and providing treatment without physician orders. Findings include: 1. Review of the facility's policy titled, Medication Orders revised November 2014, revealed Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route and rationale. Review of R30's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 10/01/24 with medical diagnoses that included acute respiratory failure. Review of R30's admission Minimum Data Set (MDS) located in the EMR under 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 record review, interview, and facility policy review, the facility failed to ensure there was ongoing pre- and post-dialysis communication for a resident receiving dialysis three times a week for one out of one resident (Resident (R)59) reviewed for dialysis out of a sample of 33 residents. This had the potential to affect all residents receiving dialysis. Findings include: Review of R59's Face Sheet, located in the Profile tab of the EMR, revealed that R59 was readmitted on [DATE] with a diagnosis of end-stage renal disease (ESRD). Review of R59's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 09/22/24 located under the MDS tab of the EMR, revealed R59 scored 14 out of 15 on the BIMS, indicating no cognitive impairment. Further review revealed the resident received hemodialysis treatment. Review of R59's Care Plan, located under the Care Plan tab of the EMR dated 12/11/21, revealed the resident required dialysis three times weekly. Review of R59's Physician Orders located…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure residents received medications as ordered by the physician for four of eight residents (Resident (R) 4, R33, R135, and R12) reviewed for medications of 33 sample residents. This failure could result in unwarranted medication side effects and mismanaged medical conditions. Findings include: 1. Review of R33's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed re-admission to the facility on [DATE] with a diagnosis of anemia in chronic kidney disease. Review of R33's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 09/10/24, revealed the Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating no cognitive impairment. Review of R33's care plan located under the ''Care Plan'' tab of the EMR and dated 05/20/24, revealed ''The resident has anemia. Interventions in place were to give medications as ordered.…

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, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than five percent during observation of medication administration. The facility had four errors in thirty-one opportunities, which resulted in a 12.9 percent error rate. This affected two (Resident (R) 135, and R12) out of three residents observed. Medication errors have the potential to result in adverse health outcomes. Refer to F658 and F755. Findings include: Review of the facility's Adverse Consequences and Medication Errors policy, revised August 2014, revealed, the definition of a medication error is 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. Examples of medications errors include: omission - a drug is ordered but not administered, .wrong dose, . 1. Review of R135's admission 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 observation, staff interview, and review of facility policy, the facility failed to ensure that one of medication carts on Unit 3 Hall was secure when staff were not present. This had the potential to affect all residents on that hall or who were walking by the cart. As well as the facility failed to sure resident medication were secure at time of administration for one for 33 sampled resident (R37.) Findings include: 1. Observation on 11/11/24 at 10:12 AM revealed a medication cart sitting in the hallway outside room [ROOM NUMBER] was not locked and the computer screen was slightly pushed down but the screen was not locked. There was one resident in a wheelchair using the cart to pull himself past in his wheelchair. There was a housekeeping staff, therapy staff and a visitor that walked by. During an interview on 11/11/24 at 10:17 AM Licensed Practical Nurse (LPN) 6 walked up and stated she knew it was unlocked. She did not answer any questions and stated, it's locked now and walked away. 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, record review, interview, and policy review, the facility failed to follow infection prevention standards during a medication pass, which included not disinfecting glucometer's between residents, for two of two residents (Resident (R) 282, R135) observed. This created a potential for the transmission of blood borne illness to residents who had blood sugar checks. Findings include: Review of the facility's Handwashing/Hang Hygiene policy, revised August 2014, revealed, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after coming on duty; before and after direct contact with residents; before preparing or handling medications; . After contact with a resident's intact skin; .After removing gloves; . Review of the facility's Blood Glucose Meter Cleaning policy, dated 10/05/18, revealed, If blood glucose meters must be shared, the device should be cleaned and disinfected…

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 have evidence of preventing further abuse while the investigation was in progress for 1 of 2 facility self-reports (R7) reviewed for abuse, neglect, and mistreatment. * The facility's self-report dated 2/5/24 indicates on 2/4/24, R7 alleged a staff member yanked on R7's arm while performing cares. The facility self-report stated the alleged Certified Nursing Assistant (CNA) was sent to the rehab side of the building after the allegations on 2/4/24 to continue working with other residents. The facility did not protect residents from potential further abuse by allowing the CNA to continue working with other residents on another unit. Findings Include: Surveyor reviewed the facility's Policy and Procedure, Abuse, Neglect and Exploitation dated 9/2020, last reviewed 1/5/2024, noting the following as applicable: 1. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports 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 a copy of R4's medical records in 48 hours after request. R4 was not provided copies of his medical record within 48 hours of his family members request who was acting on the request of R4. No follow up with R4 was made until 2/20/24 and the original written request was 2/6/24. Findings include: R4 was admitted to the facility on [DATE]. R4's medical record was reviewed on 2/19/24 and indicated he was responsible for himself and makes his own decisions, On 2/20/24 at 10:30 AM Family Member (FM)-D was interviewed and indicated that she was trying to get medical records for several weeks for R4 and had not received them yet. FM-D indicated she put in a written request on 2/6/24 and nothing had been received yet. On 2/20/24 at 11:35 AM [NAME] Clerk (WC)-C was interviewed and indicated she had not tried to get R4 to sign a release for his medical records until today. WC-C indicated R4 never refused to sign the form and FM-D had requested R4's medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the reporting of a reasonable suspicion of a crime, for 1 (R2) of 1 resident's with allegations of abuse, to law enforcement. On 2/8/2024 R2 was involved in an altercation while in the facility and was hit in the chest by roommate R3. Law Enforcement was not contacted immediately after the allegation of R2 being struck. Findings include: Surveyor reviewed the facility's Policy and Procedure, Abuse, Neglect and Exploitation dated 9/2020, last reviewed 1/5/2024, noting the following as applicable: VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . R2 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 did not revise 2 of 2 resident (R2 and R3) care plans after a resident to resident altercation occurred. * The facility's self-report dated 2/8/24 indicates that on 2/8/24 R2 alleged being hit in the chest by roommate (R3). The facility self-report stated the intervention was to transfer R2 to another room. The facility did not update R3's care plan to increase supervision when R3 was out of their room and around other residents including R2. The facility did not update R2's care plan to provide increased supervision of R2 should R2 and R3 encounter each other while outside their rooms. Findings include: R2 was readmitted to the facility on [DATE] with diagnoses that include parkinsonism, dysphagia, cerebellar ataxia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness, and adult failure to thrive. The admission MDS (Minimum Data Set) dated 12/4/2023 indicates R2 was not assessed for BIMS (Brief…

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 4. R32 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus type 2, hypertension, and cerebral vascular accident with aphagia and dysphasia. R32's annual Minimum Data Set (MDS) assessment dated [DATE] documented R32's Brief Interview for Mental Status was not completed due to R32 being rarely or never understood; R32 weighed 154 lbs (pounds) and had a 5% or more weight loss in last month or loss of 10% or more in the last 6 months not on a physician prescribed weight loss regime; R32 received more than 51% of nutrition via tube feeding while a resident and over the seven day look back period. R32's care plan, initiated 6/27/23 and revised 11/2023, stated R32 has a nutritional problem r/t (related to) protein calorie malnutrition, hx (history) of sig (significant) wt (weight) loss, problems swallowing, DM2 (diabetes mellitus type 2), receiving enteral nutrition to meet all nutritional/hydration needs, NPO (nothing by mouth).11/2023 - sig wt loss x 90 and 180 days -TF rate…

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 4. R43 was admitted to the facility on [DATE] on hospice care and had diagnoses including Vascular Dementia, unspecified severity, without behaviors; Depression, Anxiety, Parkinson's Disease; cognitive communication deficit and muscle weakness. R43's most recent quarterly Minimum Data Set (MDS) assessment, dated 9/22/23, documented R43 had a Brief Interview for Mental Status of 3, indicating R43 had severe cognitive impairments; R43 had hallucinations and delusions, R43 did not exhibit any physical, verbal, or other behaviors; R43 had rejected of care one to three days during the look back period and R43 received antipsychotics on a routine basis only with no gradual dose reduction due to physician documenting contraindication. R43's high risk drug classification use and indication section of this MDS, which documented use of antipsychotics, antidepressants, antianxiety medications and other high risk medications with documented indications for use was left blank. R43's psychotropic medication 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 interview and record review, the facility did not (1) implement an established process of assessing a resident's cognitive ability to understand an arbitration agreement before obtaining a signature for 2 (R288 and R21) residents; and (2) ensure that the staff responsible for the arbitration agreement was able to thoroughly explain the agreement for complete understanding. This deficient practice had the potential to affect 55 of 86 residents who resided in the facility that entered into the binding arbitration agreement. Findings include: According to the regulation at 42 CFR (Code of Federal Regulations) under 483.70 (n) Binding Arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) Agreements, Binding Arbitration Agreement (Arbitration Agreement) was defined as, .a binding agreement by the parties to submit to arbitration all or certain disputes [disagreements,…

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 have an effective infection control program to help prevent the transmission of infections with residents on transmission based precautions with the potential to affect all residents residing on unit one which had a population of 14 residents. * R19 had a diagnosis of Clostridioides difficile (C.Diff) and was placed on contact isolation and who was taken off of contact isolation on 12/20/23. On 12/19/23, Licensed Practical Nurse (LPN)- H was observed using medical equipment on R19 and placing it in and on the medication cart without sanitizing it after use. The LPN was also observed to have placed her used personal protective equipment (PPE) in the garbage can on the medication cart. The LPN did not wash her hands with soap and water before coming of of R19's room. * On 12/20/23, Surveyor observed a Certified Nursing Assistant (CNA) - Z enter R64's room who was in Covid-19 isolation. CNA did not wear a gown, face shield or gloves when…

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 comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives) for 1 (R288) of 19 residents reviewed for Advanced Directives. R288 was incapacitated at the time of admission and was unable to receive information or articulate whether or not he or she has executed an advance directive, the facility did not give advance directive information to the individual's resident representative in accordance with State law. R288's Power of Attorney (POA) was activated at the hospital prior to admission and the facility was unaware and had R288 sign his own admission paperwork. Findings include: Surveyor reviewed the facility's Advanced Directives policy with a revision date of April 2013. Documented was: Advance directives will be respected in accordance with state law and facility policy. 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the 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 record review and interview, the facility did not complete a Preadmission Screening for individuals with a mental disorder as required for 1 (R51) of 3 residents reviewed for Preadmission Screening and President Review (PASARR). R51 was admitted to the facility with diagnoses of bipolar disorder, major depressive disorder, schizophrenia, and anxiety disorder. A Level I PASARR was not completed and submitted to the State Agency prior to admission that would have triggered a Level II PASARR to be completed. Findings include: The facility policy and procedure entitled PASARR Guideline dated 11/28/2017 states: Level I and Level II Screen - In brief, the PASRR process requires that all applicants to Medicaid-certified Nursing Facilities be given a preliminary assessment to determine whether they might have SMI/SMD or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in a determination…

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 1 (R37) out of 19 residents sampled for care planning had a comprehensive care plan developed that included individualized approaches to care to maintain highest level of functioning and safety. The facility did not develop a comprehensive care plan identifying pain relieving measures for R37 who was admitted to the facility after being hospitalized for hemarthrosis of left knee and had chronic pain. Findings include: On 12/18/23 11:55 AM and 12/20/23 at 8:31 AM Surveyor interviewed R37. Surveyor asked about R37's pain. R37 stated he has a history of broken bones and chronic pain. R37 stated most recently he fell and his leg bent all the way back and he cannot move his foot. Surveyor asked if his pain is controlled. R37 stated sometimes. Surveyor reviewed R37's medical record which included in part; R37 was admitted to the facility on [DATE] with diagnoses that included Chronic Pain, Muscle Weakness, Spondylolisthesis, Polyneuropathy,…

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 care and services so that 1 of 2 sampled residents (R43) reviewed with a diagnosis of Dementia and was receiving multiple medications could reach their highest physical, mental, and psychosocial well-being. Findings include: The Facility policy entitled Dementia Treatment and Services, effective date 06/29/2021 stated, Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills .Behavioral or psychological expressions are occasionally related to the brain disease in dementia; however, they may also be caused by or exacerbated by environmental triggers. Such expressions or indications of distress often represent a person's attempt to communicate an unmet need, discomfort, or thoughts that they can no longer articulate. Medications may be effective when the underlying cause of a resident's distress has been determined and non-pharmacological approaches to care have been ineffective…

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 pharmaceutical services, including services that assure the accurate storage, dispensing and administering of all drugs and biological's to meet the needs of residents for 2 of 5 resident (R33 and R287) investigated for proper medication administration. *R33 was observed to have her insulin pens dialed up and prepared by one Licensed Practical Nurse (LPN)-K and administered by another LPN-N. LPN-N who administered the insulin did not sign out that they administered it. LPN-K who prepared the medication signed it out. * R287 came in with orders for intravenous antibiotics every 12 hours and did not receive it until she went to the emergency room for administration. Findings include: 1. R33 was admitted to the facility on [DATE], with diagnosis that included type 2 diabetes. On 12/19/23 at 8:44 AM Licensed Practical Nurse (LPN) -K was observed preparing insulin for R33. LPN-K then gave the insulin pens to LPN-N who was orientating with LPN-K and…

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

Based on observation, interview and record review the facility did not ensure that it maintained a medication error rate below 5 percent during observations of medication administration affecting 2 (R33 and R19) of 4 residents observed. Five medication errors were observed out of twenty-eight opportunities, for a total error rate of 17.85 %. * On 12/19/23, R33 received Lantus and Humalog insulin from an insulin pen and the needle was not primed before administration. *On 12/19/23, R19 was given Carvidilol, Hydroxine and Dicyclomine which are medications given more than once a day was given 2-3 hours after the written administration time. Findings include: 1. On 12/19/23 at 8:44 AM Licensed Practical Nurse (LPN)-K was observed preparing insulin for R33. LPN-K dialed one unit of Lantus insulin on the pen and then pushed the plunger. LPN-K then attached the needle and dialed 12 units without priming the needle. LPN-K then dialed one unit of Humalog insulin on the pen and then pushed the plunger. LPN-K then attached the needle and dialed 6 units without priming the needle. LPN-K then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not offer the influenza immunizations for 1 (R32) of 5 residents reviewed for immunizations. * R32 was not given the influenza immunization as of the time of the survey and had an pintail admit date of 2/8/21. Findings include: The facility policy and procedure entitled Influenza Vaccine dated 11/12 which read: Prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the residents medical record. R32 was admitted to the facility on [DATE] and has an activated power of attorney for healthcare. On 12/21/23 R32's influenza vaccination records were reviewed and indicated R32 had the vaccination in 2021 and 2022 but not in 2023. On 12/21/23 at 2:46 PM Director of Nurses-B was interviewed and indicated that R32's power of attorney was not able to be reached for consent 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 interview, record review, and facility policy review, the facility failed to ensure one of eight sampled residents (Resident (R) 5) whose drug regimen was reviewed was free from a significant medication error. R5 received two doses of short-acting insulin, administered by two different nurses, resulting in the potential for R5 to have a hypoglycemic (low blood sugar) reaction. Findings include: Review of R5's undated admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R5 was admitted to the facility on [DATE], with a readmission on [DATE], with a diagnosis of diabetes, chronic kidney disease and hypertension. Review of R5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/23, located in the EMR under the MDS tab, indicated R5 had a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated the resident was cognitively intact. The MDS also indicated R5 had a diagnosis of diabetes. Review of R5's current Physician…

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.