Chicago Ridge SNF

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and failed to protect one resident (R12) from physical abuse by R148. This failure affected one (R12) resident in a sample of 63 residents reviewed for abuse. These failures resulted in R12 being physically assaulted by R148, causing R12 to sustain bruising of right eye, right elbow, and multiple rib fractures that required hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the ice machine and the ice machine filter were kept clean and free of dust; and the ceiling air vent above the juice dispenser was free of accumulated dust. These failures have the potential to affect all 197 residents that receive oral foods from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to provide wound care services in alignment with professional practice standards by permitting a wound care Certified Nurse Assistant to remove a stage 4 sacral area wound dressing and clean the wound site. The facility failed to have the low air loss mattress at the correct weight settings. The facility also failed to provide wheelchair cushions as a pressure ulcer prevention intervention for residents at risk for pressure ulcers. These failures have the potential to affect six residents (R1, R6, R11, R16, R21, and R46) reviewed for pressure ulcer care, prevention, and interventions, in a total sample of 63 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift on the first floor and failed to ensure the narcotic count was correct for two residents on the second floor. These failures have the potential to affect nine residents (R24, R31, R60, R63, R102, R18, R148, R185, and R221) receiving controlled substances on the first floor and two residents (R151 and R163) receiving controlled substances on the second floor reviewed for medication administration in a sample of 63 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were five medication errors out of 26 medication opportunities, resulting in a 19.23% medication error rate and affected four of four residents (R40, R95, R171, and R179) observed for medication pass.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the opened container of the multi blood glucose test strips was labeled with the open date. These failures have the potential to affect six residents (R27, R63, R115, R122, R185, and R221) who received blood glucose monitoring tests residing on the first floor and reviewed for laboratory storage in the sample of 63 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's indwelling urinary catheter drainage bag was covered with a privacy bag to maintain resident's right to privacy and dignity. This failure affected one resident (R19) of two residents, reviewed for privacy and dignity, in a total sample of 63 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy by failing to obtain informed consent for increasing dosage of psychotropic medication and failed to document symptom/behaviors for the use of the medication or any non-pharmacological behavioral interventions attempted prior to increasing the dosage of the medication. This failure affected one (R161) of five residents reviewed in a sample of 65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the restorative needs and provide a left-hand resting hand splint for one resident with hand contracture to prevent further decline. This failure affected one resident (R21) of two residents, reviewed for restorative care, in a total sample of 63 residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow their medication administration policy by leaving medications at the bedside and failed to ensure that residents remained free from significant medication errors for two (R158 and R179) residents reviewed for medication administration in a sample of 63 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a dependent resident with making transportation arrangements to scheduled appointments, failed to notify physician about missed appointments and failed to re-schedule the appointments. This failure affected one (R179) of 4 residents reviewed in a sample of 63.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain consistent hospice communication for one (R16) of two residents reviewed for hospice care in the sample of 63 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their infection control and hospice services policy ensuring hospice service professionals adhered to all facility policies and procedures related to infection control when in the facility by failing to adhere to the enhanced barrier precautions designation by failing to use a gown during high contact resident care while changing a resident's incontinent brief for one (R3) resident, and failed to transport/handle linen in a manner that prevents contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to post nursing staffing information in a highly visible area for residents and failed to include required information. These findings have the potential to affect all 199 residents that reside within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the outside dumpster garbage disposal was covered with lid and failed to ensure that the floor around the dumpsters were free of trash, thus creating an unsanitary environment. These failures have the potential to cause harboring of rodents which can affect all 199 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure direct care staff were involved in the completion of the facility assessment, failed to consider staffing needs by shift and resident unit. This failure has the potential to affect all 199 residents that reside within the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow its Community Access Determination policy by not completing required Community Survival Skills assessments at least quarterly, annually, and when residents requested outside passes. This failure affected four of four residents reviewed for Social Services assessments (R1, R10, R17, and R18) in a sample.

Inspectors wroteBased on interview and record review, the facility failed to follow its grievance policy by not documenting, investigating, and providing a timely written response to a resident grievance regarding a missing phone. This deficient practice affected one of three residents (R10) reviewed for grievances.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy to prevent a resident-to-resident physical assault. This deficiency affected two of three residents (R10 and R11) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement appropriate interventions to supervise and monitor a resident (R11) with a known history of aggressive behavior to prevent entry into another resident's room. This failure affected two of three residents reviewed for supervision. (R10, R11). As a result, R11 was not adequately supervised and was able to enter R10's room, where R11 verbally and physically assaulted R10.

Inspectors wroteBased on interview and record review the facility failed to have an effective contraband policy to prevent illicit drugs from being brought into the facility, distribute and used by the residents. The facility failed to develop a plan to determine how the illicit drugs are coming into the facility. This affects 2 of 2 (R7 and R14) residents that tested positive for fentanyl and opiates and had the potential to affect all 13 (R3, R4, R6, R7, R8, R14, R16, R17, R18, R19, R20, R22, and R23) residents reviewed for illicit substance/contraband within the facility. R7 was observed slumping forward in the wheelchair, fell to the floor, was cyanotic and required Narcan (opioid antagonist/opioid reversal agent) to be given. R14 was transported to local hospital emergency room for a change in condition. R14 tested positive for fentanyl and opiates metabolites.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its medication administration policy and consistently monitor the effectiveness of pain medication. The facility also failed to accurately document the administration of controlled substances for 1 resident (R7) out of 3 reviewed for receiving high alert medications in a sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent incident of resident-to-resident physical assault. This affected three of three residents (R1-R3) reviewed for physical abuse/assault. This failure resulted in R1 physically assaulting R2 and R3, however as a result of the assault, R1 sustained bilateral nasal bone fracture and blunt abdominal trauma.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a homelike environment and ensure that the window drapes were not falling off the curtain rod/track/hooks for 10 of 10 residents (R1, R7, R8, R9, R10, R11, R12, R13, R14, and R15) reviewed for homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a policy to ensure a resident is supervised and monitored to prevent resident from leaving the facility unauthorized or without staff knowledge. These failures affected one (25) of one resident reviewed for supervision to prevent an unauthorized exit from the facility. This failure resulted in R25 leaving the facility through a window unauthorized or unknowingly to facility staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all elevators were working in the facility. This affects 4 residents (R1, R2, R9, and R24) that require services/care in the facility. Findings Include: On 7/26/25 during the survey tour one of the two elevators in the facility was observed not working. The elevator, to the left (front facing), was observed with a number one in the display box, the number did not change when the call button was pressed. On 7/26/25 at 1:37pm V7 (Maintenance staff) said the elevator company repaired the elevator yesterday 7/25/25. He was notified last night that the elevator went out again. V7 said the elevators breaking down has been an ongoing issue at the facility. V7 denied knowing what the elevator service company mention as the problem for the continue breakdown of the elevator. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their stated protocol for signing residents out on community pass by not verifying the identity of the individual who signed out a resident (R11). The facility did not have an effective supervised community pass protocol in place. This failure applied to one (R11) of two residents reviewed for community pass and resulted in R11 leaving the facility on pass on 4/30/2025 and not returning. R11 has a significant history of substance abuse disorders and R11's whereabouts are currently unknown.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to timely provide foot care treatment and ensure that residents received follow up visits per physician orders and recommendations for residents at risk for foot disorders. This failure applied to two (R5, R6) of three reviewed for podiatrist services.

Inspectors wroteBased on interviews and record reviews the facility failed to have a system in place for monitoring and investigating how illicit drugs got into the facility, to be alerted when illicit drugs enter the facility and to prevent resident use and possible drug overdose. This failure applied to one (R12) of three residents reviewed for supervision and resulted in R12 obtaining and using illicit drugs while in the facility, that led to a drug overdose, requiring the administration of Narcan (opioid reversal agent) and emergent hospital transfer.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policies and procedures for providing services and supports for chemical dependence and substance abuse by not offering substance abuse group programming to a resident who reported a history of substance abuse and not ensuring a resident with a diagnosis history of Psychoactive Substance Abuse Disorder received psychiatric, group, or behavioral health counseling and services for two (R7, R12) of three residents reviewed for behavioral health services. These failures resulted in R12 using illicit substances in the facility and requiring emergent transfer to local hospital for overdose.

Inspectors wroteBased on interview and record review the facility failed to follow professional standards of care to transcribe and follow the physician orders for one of one resident (R1) to monitor the right foot for increased discoloration, to assess pedal pulse, and monitor for temperature changes. This affects one of three residents reviewed for professional standards.

Inspectors wroteBased on interviews and record review, the facility failed to protect a resident's right to be free from physical abuse from another resident for one (R5) of five residents reviewed for abuse in a sample of 14. This failure resulted in R5 being physically assaulted and emergently transferred to the hospital for evaluation of facial trauma. Findings inlcude: R5 was dmitted to the facility on [DATE] with diagnosis including but not limited to Gout, Unspecified; Hypothyroidism, Unspecified; Chronic Obstructive Pulmonary Disease, Unspecified; Essential (Primary) Hypertension; Hyperlipidemia, Unspecified; Other Muscle Spasm; and Nondisplaced Fracture of Cuboid Bone Of Right Foot, Subsequent Encounter For Fracture With Routine Healing. [...]

Inspectors wroteBased on interviews and record review, the facility failed to assess and identify resident's new onset of right hip pain and administer PRN (as needed) pain medications for one (R8) of three residents reviewed for pain in a sample of 14. This failure resulted in R8 having increased pain level for 24 hours before R8 was hospitalized for pain management and later surgery of the right hip fracture.

Inspectors wroteBased on interviews and record review, the facility failed to notify a physician of a resident refusing psychotropic medication for one (R7) of three residents reviewed for quality of care in a sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to keep a resident free from verbal abuse from a staff member. This failure applied to one (R1) of one resident reviewed for abuse.

Inspectors wroteBased on observation, interview and record review the Facility failed to maintain an effective pest control program to effectively exterminate pests (cockroaches) in the Facility. This failure has the potential to affect all 205 Residents residing in the Facility.

Inspectors wroteBased on interview and record review the Facility failed to follow Care Plan interventions and implement appropriate fall prevention interventions to prevent repetitive falls for one of three Residents (R2) reviewed for falls in a sample of four.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their call light policy and procedures by not promptly answering residents call lights. This failure applies to five (R6, R7, R13, R14, R15) of 15 residents reviewed for call light response.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their grievance policy and procedures by not ensuring that a concern reported to staff regarding assistance with activities of daily living was documented, investigated, followed up on, and resolved. This failure applies to one of fifteen residents (R7) reviewed for grievance procedures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to ensure that a resident who was assessed to not be able to navigate safely and independently in the community, leave the facility unsupervised. This failure applied to one (R1) of one residents reviewed for supervision and resulted in R1 eloping from the facility on 01/10/25 with no access to ordered medical care and was subsequently found (at an undetermined date) intoxicated by local police and taken to local hospital. The Immediate Jeopardy began on 01/10/25 when R1 eloped from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 01/22/2025 at 3:39 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff were available to ensure medications were administered as ordered to 34 residents (R1, R4, and R6-R37). This failure has the potential to affect 34 residents ordered to received medication from third floor front cart.

Inspectors wroteBased on interview and record review, the facility failed to provide medications to 34 residents (R1, R4, and R6-R37) as ordered by the prescriber to meet the needs of each resident. This failure has the potential to affect thirty-four residents receiving medication from third floor front cart.

Inspectors wroteBased on interview and record review, the facility failed to provide significant medications to five residents (R1, R16, R26, R33 and R37) on 12/25/2024 on day shift. This failure affected five of thirty-four residents reviewed for significant medication.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect a resident (R2) from resident-to-resident physical abuse. This failure affected one (R2) of four residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and ensure residents received garlic Texas toast with the lunch meal on 12/18/24 and oatmeal and scrambled eggs with cheese with the breakfast meal on 12/20/24 for all 211 residents who receive meals in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that there were plates, cups, eating utensils, and napkins available for each resident during the lunch meal service. This failure has the potential to affect all 75 residents residing on the third floor nursing unit.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to follow its care plan policy and initiate an individualized falls care plan with interventions, implement fall precautions immediately to prevent a fall, and adequately supervise a resident at moderate risk for falls. This failure affected one resident (R2) out of three reviewed for falls in a sample of 18.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its fall risk and post fall assessment policy and accurately assess the resident's fall risk upon admission, identify and implement fall prevention interventions immediately to prevent a fall. This failure affected one resident (R2) out of three reviewed for falls in a sample of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that was clean and free of pervasive odor of urine in residents' rooms, failed to ensure that residents rooms are cleaned, and that garbage is properly disposed, failed to properly dispose of wet, soiled, stained linens from resident's room, and failed to properly clean or replace soiled mattresses. This failure affected seven of seven residents (R1, R4, R5 R6, R7, R8, R10) reviewed for environment and has the potential to affect all 67 residents residing on the third floor of the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for serving food under sanitary conditions and ensuring residents meals are served in a manner to maintain appropriate serving temperatures by not covering meal trays with lids during dining service. This failure applied to all (66) residents receiving meals on the 2nd floor of the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure documented alternate communication methods were used to maintain communication for a resident with a communication barrier. This failure applied to one (R2) of eleven residents reviewed for quality of life and care.

Inspectors wroteBased on interview and record review, the facility failed to ensure an altercation between two residents (R1 and R4) was identified and investigated as abuse. This failure applied to two (R1, R4) of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure transmission-based precaution (PPE, isolation signage and set-up, resident/employee/visitor screening) and infection surveillance were implemented during COVID 19 outbreak. These deficiencies affected 14 residents (R5, R7, R38, R64, R69, R90, R99, R114, R147, R148, R150, R155, R158, R142) and has the potential to affect the rest of 180 residents residing in the building.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy in alerting a resident's responsible party of a change in condition. This failure affects one (R3) of two residents reviewed for notification of responsible party of resident's change in condition in a sample of 35.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for providing effective pest control interventions by not adequately assisting residents with maintaining a clean environment and not providing pest control treatments consistently. This failure applies to all 202 residents currently in the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their environmental policy and procedures by not ensuring resident living areas were kept free of mold or mold promoting conditions. This failure applied to three of three residents (R1, R13, and R14) reviewed for environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedure for wound treatments by not ensuring residents received wound treatments daily as ordered by the physician, with multiple missed wound treatments. This failure applied to two of three residents (R1 and R3) reviewed for wound care.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedures for internal reporting requirements of abuse allegations by not reporting a family reported allegation of abuse to the abuse coordinator (Administrator). This failure applied to one of three residents (R2) reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure bed linens were changed as needed for a resident who requires assistance with activities of daily living. This failure applied to one of three residents (R1) reviewed for activities of daily living.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for weight management by not ensuring specialized dietary orders were followed, not following a physician's supplemental recommendations from hospital records, not honoring a residents supplemental preference, not accurately documenting supplement administration, not obtaining dietary preferences, not providing feeding assistance as needed, and not accurately documenting meal consumption for a resident at high risk for and exhibiting signs of severe malnutrition. This failure applied to one of one resident (R1) reviewed for nutrition status.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for providing specialized diets by not ensuring specialized dietary orders were followed and not providing feeding assistance as needed for a resident who receives a mechanical soft diet. This failure applied to one of one resident (R1) reviewed for specialized diet.

Inspectors wroteBased on interview and record review the facility failed to follow the plan of care and provide Activity of Daily Living to a resident dependent on staff for incontinent care. This affects one of 3 residents (R4) reviewed for activities of daily living care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for behavior Management for Agitated Behavior by not providing one to one supervision for a resident, with a history of self-harming behavior, who was threatening and attempting self-harm and being physically aggressive towards staff. This failure applied to one of three residents (R9) reviewed for accidents and injury and resulted in R9 sustaining a fracture to their right arm.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident. This failure applied to two of two (R5, R15) residents reviewed for abuse.

Inspectors wroteThere are two separate deficient practices statements for this citation. I. Based on interviews and records reviewed the facility failed to develop a plan of care to prevent a resident with a history of suicidal ideation from obtaining items that can cause self-harm. This failure affected one of three residents (R4) reviewed for safety and supervision in the sample. This failure resulted in R4 being able obtain a belt and was found hanging from a towel rack on the bathroom floor on 02.29.24. The Immediate Jeopardy began on [DATE]. V12 and V13 (both Administrators) were notified on [DATE] at 10:53AM of the Immediate Jeopardy. [...]

Inspectors wroteBased on interviews and records reviewed the facility failed to develop interventions for one resident (R4) with a history of suicide ideation with a plan for skill groups, including suicide prevention group, and failed to provide therapeutic programming. The facility failed to develop a plan for check in to assess daily mood or notify the attending psychiatrist of R4's change in mood which documents feeling down, depressed, or hopeless nearly every day. This failure resulted in R4 found unresponsive hanging from a towel rack in his bathroom. This failure affected 1 of 3 residents reviewed. R4 was pronounced dead in the hospital on 3/5/24. The Immediate Jeopardy began on 2/29/24 V12 and V13 (both Administrator) was notified on 3/21/24 at 10:54AM of the Immediate Jeopardy. The facility presented an initial removal plan on 3/21/24. [...]

Inspectors wroteBased on observation and interview the facility failed to provide one resident (R14) with clean and untorn socks at his request. This failure affected one of three residents reviewed for resident rights in the sample.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision, assistive devices and proper transfer technique to prevent a fall of 1 (R1) of 3 residents reviewed for accident/hazards in the sample. This failure resulted in R1 being emergently transferred to the hospital after a mechanical fall during transfer from bed to chair causing excruciating pain and femoral fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly prevent and contain the spread of Covid-19 and other infectious diseases by failing to ensure a posting at the entrance to the facility of active Covid-19 infection; failing to implement source control measures regarding the use of face masks when Covid-19 is present in the facility; failing to ensure alcohol based hand rub was available in the PPE (personal protection equipment) carts for transmission based precaution isolation rooms; failing to ensure dedicated or disposable non critical resident care equipment was available for transmission based precaution isolation rooms; and failing to ensure all residents, their representatives and families were notified following the occurrence of either a single confirmed infection of Covid-19 or three or more residents or staff with new onset of symptoms. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to follow their abuse policy and procedures by not ensuring a care plan was implemented for a resident when they were initially observed engaging in verbally and physically aggressive behaviors. This failure applies to two of four residents (R11 and R12) reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prevent the misappropriation and/or diversion of medications for two (R2, R17) of three residents reviewed for medication administration; and failed to follow their facility's ordering and receiving of medications policy. This failure resulted in R2's pain medication (ibuprofen) being reordered in excess with minimal documentation of medication being administered to R2; and failed to have both resident's (R2, R17) personal medication supply readily available upon request for administration on numerous occasions.

Inspectors wroteBased on interview and record review, the facility failed to monitor and assess a resident's (R13) condition who was receiving blood thinner medication and had previous laceration; and failed to have an active care plan for a resident (R14) for diabetes care and act promptly to provide an intervention for a resident with low blood sugars. These failures involved two residents, R13 and R14. As a result, on 11/10/23 R13 was found lying in a moderate amount of blood in bed and sent to the hospital via 911 emergency. On 11/11/23 R14 was found lying on the floor unresponsive and sent out via 911 after paramedics administered a blood glucose check and which the result of was a hypoglycemic reading.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing coverage on specific days and shifts, causing call lights not to be answered and not ensuring adequate resident care and assistance for three of three residents (R4, R8 and R13) reviewed for staffing. Findings Include: Per residents' census report dated 01/02/24, there are 186 residents currently residing in the facility. On 01/02/24 at 2:23 PM, R4 mentioned during an interview that call lights were not answered by staff in a timely manner. R8 and R13 verbalized concerns regarding staffing in the facility. R4, R8 and R13 stated call light responses, provision of care and necessary support from staff were issues due to lack of staff. V38 (Staffing Coordinator) was interviewed on 01/08/24 at 9:27 AM regarding staffing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide medications and/or biologicals, as ordered by the prescriber to meet the needs of each resident and failed to provide pharmaceutical services to meet each resident's needs which includes acquiring, receiving, dispensing, accurately administering, or disposing of medications. This failure affected one resident (R17) of four residents reviewed for medication administration, causing the resident to endure pain related to not having pain medication available when needed.

Inspectors wroteBased on observation, interviews and records reviews the facility failed to ensure to continue to provide substance abuse maintenance medications for one resident admitted with opioid dependency. This failure affected one of three residents reviewed for treatment orders followed in the sample. This resulted in one resident (R372) not receiving her medication for 3 days, following admission to the facility. R372 reported not feeling well, being sweaty, and staff observed R372 to be fidgety. In addition, the facility failed to follow MD orders by not securing an abdominal wound dressing. This affected one of three residents (R222) reviewed for wound dressing in the sample. This failure resulted in R222 not having the dressing change at least twice a day which left the wound and wound packing exposed with noted fecal matter on the wound area.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's medication was available for administration for more than 72 hours following admission. This failure affected 1 (R372) of 2 residents reviewed for missed medication. This failure resulted in R372 reporting they were not feeling well, being sweaty, and staff observing R372 to be fidgety.

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to ensure to provide evidence to support sufficient nursing staff based on the facilities staffing numbers. This affected two of two residents (R138, R222) reviewed for staffing. This has the potential to affect all 191 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dessert cooler, three compartment sink and ventilation hood were in good working condition. This failure has the potential to affect all 191 residents at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy titled food safety and sanitation when handling food during meal service.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program. This failure affected 5 of 5 (R90, R24, R102, R58, R272) in the sample reviewed for pest control. This has the potential to affect all 191 residents. Findings Include: According to the CMS 672 dated 10/16/23 there are 191 residents in the facility. On 10/15/23 at 10:17AM, a dead medium size dark brown elongated bug consistent with a roach was seen on its back in the kitchen's dry storage area behind the refrigerator. V26 (Dietary) said, he was not sure what type of bug was dead behind the refrigerator. On 10/15/23 at 10:28AM, multiple crawling small and medium size brown bugs consistent with roaches were observed in R90 and R24's room and bathroom. R24 said, we have roaches. The roaches are all under our items. Just move anything and they will come out. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents are aware of where the ombudsmen contact information is posted in the facility. This affects eight of eight residents (R5, R26, R45, R79, R80, R135, R152, and R274) in the sample of 36 reviewed for residents rights for ombudsmen postings.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the state inspection is available for the residents to read without having to ask the staff for them. This affected eight of eight (R5, R26, R45, R79, R80, R135, R152, and R274) residents in the sample of 36 resident reviewed for residents rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Oxygen Equipment Policy. The facility failed to date oxygen tubing and prefilled humidifier. This affected five of five residents (R46, R62, R140, R425 and R427) reviewed for oxygen administration in a total sample. Findings Include: On 10/15/23 at 10:45AM, R62 observed to have an oxygen concentrator at bedside, oxygen tubing dated 9/10/23, and empty prefilled humidifier dated 4/9/23. On 10/15/23 at 10:50AM, R46 observed to have oxygen concentrator at bedside, oxygen tubing and prefilled humidifier not dated, and humidifier bottle is empty. On 10/15/23 at 11:10AM, R140 observed to have oxygen concentrator at bedside and prefilled humidifier bottle not dated. On 10/15/23 at 11:15AM, R425 observed to have oxygen concentrator at bedside, oxygen tubing and prefilled humidifier bottle not dated. [...]

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to provide clean assistive devices and assistive devices in good working order for one (R102) of three residents reviewed in the sample.

Inspectors wroteBased on interview and record review, the facility failed to clearly document an advance directive status. This affected one of three residents (R89) reviewed for advance directives in the electronic medical record.

Inspectors wroteBased on interviews and records reviewed the facility failed to notify the physician when medications were not available for greater than 72 hours. This affected one of three residents (R373) reviewed for notification of missed medications in the sample.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prevent the misappropriation and/or diversion of medications for two (R2, R17) of three residents reviewed for medication administration; and failed to follow their facility's ordering and receiving of medications policy. This failure resulted in R2's pain medication (ibuprofen) being reordered in excess with minimal documentation of medication being administered to R2; and failed to have both resident's (R2, R17) personal medication supply readily available upon request for administration on numerous occasions.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not reporting allegations of abuse for two of three residents (R69, R66) reviewed for abuse reporting. Findings Include: On 10/15/23 at 10:57am, R69 who was delusional said in 2016, she was raped while she slept. R69 said, when she awoke, she saw R7 walking out of her room in the middle of the night. R69 said, R7 raped her that night. R69 did not recall the act of being raped or when R7 was on top of her but she knew she was raped when she saw R7 walking out of her room. R69 said, she had semen in her vaginal area at that time. R69 also said, the semen is currently still in her vaginal area. On 10/16/23 at 4:38pm, V2 (regional consultant) said, R69's allegation of sexual abuse should have been reported after her hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not investigating an allegation of abuse for one of three residents (R69) reviewed for abuse reporting. Findings Include: On 10/15/23 at 10:57am R69, who was delusional, said in 2016 she was raped while she slept. R69 said, when she awoke she saw R7 walking out of her room in the middle of the night. R69 said, R7 raped her that night. R69 did not recall the act of being raped or when R7 was on top of her but she knew she was raped when she saw R7 walking out of her room. R69 said, she had semen in her vaginal area at that time. R69 also said, the semen is currently still in her vaginal area. On 10/16/23 at 4:38pm, V2 (regional consultant) said, R69's allegation of sexual abuse should have been investigated after her hospitalization. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow care plan interventions by not utilizing the communication book for communication for a resident unable to voice their needs. This affected one of three residents (R147) reviewed for communication in the sample.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide feeding assistance for one resident identified as needing feeding assistance. This affected one of three residents (R160) reviewed for feeding assistance in the sample. Findings Include: R160's diagnosis includes unqualified visual loss, both eyes and autistic disorder. Minimal data set section G (functional status) dated 9/7/23 documents: R160 requires supervision with one person physical assist with eating. Physician order sheet dated 8/16/23 documents: for diet need assistance with feeding. On 10/15/23 at 12:51PM, R160 was assisted by co-peer/another resident who was sitting at R160's table to remove the plastic wrap from a peanut butter sandwich. R160 fed self without any staff assistance. R160's co-peer offered R160 his juice and placed it in R160's hand. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow their pressure ulcer prevention interventions which include inappropriate Low Air Loss Mattress pressure setting for residents identified to be at risk for skin breakdown. This affected two of three residents (R62 and R 86) reviewed for pressure ulcer prevention and interventions in a total sample of 36 residents. Findings Include: On 10/15/23 at 10:45AM, observed R62 in bed using low air loss mattress. Machine setting is at 350 lbs. On 10/15/23 at 11:30AM, observed R86 in bed, using low air loss mattress. Machine setting is at 320 lbs. On 10/15/23 at 11:05 AM, showed V3 (DON) and confirmed that the mattress setting is set on 350 lbs. On 10/15/23 at 11:30AM, showed V11 (nurse) and confirmed that the mattress setting is set on 320 lbs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident with history of mental illness had been assessed by a mental health professional since admission. This affected one of one resident (R167) reviewed for mental health services in the sample.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their medication labeling and storage policy. This affected three of three residents (R472, R473, and R136) reviewed for medication storage in the sample. Findings Include: On 10/16/23 at 10:02am, two prescription bottles were observed in a box with old empty pill cards and paper under the 3rd floor nursing station. R472 had a prescribed bottle of amlodipine 5mg dated 7/24/23 (documents: take one tablet by mouth every day) with 22 pills inside the bottle and chlorthalidone 25mg dated 7/24/23 (documents: take one tablet by mouth every day) with 21 pills inside. V16 (ADON) said, there should not be any medication under the nursing station. All medication should be locked in the medication room until disposed of or returned. R472's physician order sheet dated 10/14/23 documents: [...]

Inspectors wroteBased on interview and record review the facility failed to maintain an effective abuse prevention training policy/practice for reporting allegations of abuse for 1 resident (R66) in sample of 36 reviewed for reporting.