Complete Care at the Boulevard

Inspectors wroteBased on interview and record review the facility failed to ensure that one resident (R1) was free from physical abuse when R2 struck R1 in the face during an altercation in their shared room. This failure affected one of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure that one resident (R1) received the correct prescribed medication. This failure caused R1 to experience symptoms of intoxication; (leaning over the table, weakness, inability to maintain upright sitting position or eat independently, decreased strength and limited ability to respond) and had to be sent out to the hospital for evaluation for receiving a medication used to treat opioid use disorder. This failure affected one resident R1 out of a sample of 3 residents. Findings Include:R1 has a diagnosis of but not limited to Spinal Stenosis, Spondylosis with Myelopathy, Hypertension, and Adult Failure to Thrive. R1 has a Brief Interview of Mental Status score of 13 that indicates intact cognition. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prevent neglect on a resident who required wound care treatment which was not completed and documented. This failure affected one resident (R1) out of three reviewed for neglect in the facility.

Inspectors wroteBased on interview and record review the facility failed to a.) follow their policies and evaluate fall risk in accordance with professional standards of practice b.) provide supervision and assistive devices consistent with a resident's needs to prevent avoidable/reduce the risk of an accident for one resident (R6) out of three residents reviewed for accidents in a total sample of eight residents. This failure resulted in R6 sustaining a fall without significant injury.

Inspectors wroteBased on record review and interview, the facility failed to ensure there was sufficient qualified dietary staff available to cook meals. This failure has the potential to affect 127 residents who received meals from the kitchen. Findings Include: On 03/28/26 at 10:47 AM V5 (Former Dietary Aide) stated V12 (Dietary Aide) and V14 (Dietary Aide) were cooks and dietary aides. V13 (Dietary Aide) has her certification but 3 other cooks are there with no certification. They tried to force me to bake but I am a dietary aide. I was scared because the oven is big and hot. On 03/28/26 at 07:26 AM During the kitchen tour there were three staff members observed working in the kitchen. V6 (Dietary Aide) was cooking and plating breakfast. V9 (Dietary Aide) was observed covering the plates with the dome covers, putting the plate and utensils on the trays. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a dietary staff member performed hygiene after removing and changing gloves while in the dish room. This failure has the potential to affect 127 residents who received meals from the kitchen. Findings Include: On 03/28/26 at 09:18 AM V7 (Dietary Aide) returned to the kitchen with food carts. V7 was observed dumping/scraping the trays, placing the utensils, plates and cups in sanitizer. V7 said if there are 2 people I would run the dishes through the dish washer, and the second person will catch the clean dishes. On 03/28/26 at 09:36 AM V9 (Dietary Aide) entered the dish room to assist. V9 observed pushing the racks with the dirty dishes into the dishwasher. V9 then removed the clean trays and put the clean dishes on a cart without changing her gloves or performing hand hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to investigate and report an allegation of Abuse for one (R1) of three residents reviewed for Abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care and assure that one resident (R1) at high risk for skin breakdown received the treatment and services to prevent the development and worsening of a new pressure ulcer. This failure resulted in R1's development and deterioration of a unstageable pressure ulcer, requiring hospitalization and surgical intervention for Sacral ulcer with underlying destruction of the coccyx.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of a resident using a mobility device. This failure affected one resident (R2) out of 5 reviewed for adaptive equipment use in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician of one (R1) resident of change in condition of three residents reviewed. This failure resulted in delaying R1's transfer to the hospital for further evaluation for a contusion and bruised right eye in a total sample of three residents.

Inspectors wroteBased on interview, and record review the facility failed to ensure there are enough nursing staff to respond to call lights in a timely manner. In a resident council minute meeting residents' complain that sometimes the facility only has one or two CNAs (certified nursing assistant) for the 2nd and 3rd shift. Review of staffing data submitted via the PBJ system revealed the facility was triggered for excessively low weekend staffing. This failure places all 104 residents in the facility at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. 02/05/25, 10:15 AM, residents agreed that the resident council meets regular, monthly. Residents' complain that sometimes they only have one CNA (certified nursing assistant) on the 2nd or 3rd shift and the call lights don't get answered for a long time. [...]

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their policy on sanitation and food safety by failing to (a) dish washer temperatures not reaching recommended temperatures, (b) properly sanitizing dishes in the three-compartment sink, (c) properly wearing hair net in the kitchen, (d) date open food item with open date and use by date. This failure has the potential to affect 101 residents who are on an oral diet.

Inspectors wroteBased on interview and record review the facility failed to ensure the designated Infection Prevention nurse completed specialized training in infection prevention and control in nursing homes. This failure has the potential to affect 104 residents residing in the facility.

Inspectors wroteBased on review of records and interviews the facility failed to ensure a Pre-admission Screening and Residential Review (PASSAR) were done for 5 out of 5 residents (R9, R15, R16, R37, R54) prior to admission. These failures have the potential to affect 5 residents (R9, R15, R16, R37, R54) in a total sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) administer residents' prescribed medications in a timely manner according to the physician orders and b.) keep an accurate count of all narcotic medications for four (R3, R24, R30, R31) residents reviewed for medications in a total sample of 21 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) remove and discard expired medications that had been open in three of six medication carts, b.) remove and discard expired enteral feedings located in one of three medication storage rooms, and c.) properly label medications that had been open for resident use. These failures have the potential to affect 68 residents residing in the facility reviewed for medication labeling and storage. Findings Include: On 02/04/2025, at 9:24 AM, surveyor and V4 (Registered Nurse/RN) located on the second floor of the facility at the medication cart performing a controlled substance count and record review. Surveyor observes the following: 1 open liquid medication bottle labeled R32s' name, Morphine Sulfate 20mg/ml inside of the medication cart. [...]

Inspectors wroteBased on interview and record review the facility failed to minimize the risk of acquiring, transmitting, or experiencing complications from influenza and Covid-19 for six residents (R27, R62, R73, R207, R257, R307).

Inspectors wroteBased on observations, interviews, and review of records the facility failed to maintain resident rights pertaining to dignity for 3 out of 3 residents (R 18, R37, R69) for a total sample of 21 residents reviewed for resident rights. Facility failures are as follows: failed to provide feeding assistant with dignity for one resident (R37); failed to protect/promote the right to confidentiality of medical information for two residents (R18 and R69). These failures have the potential to affect 3 residents (R18, R37, R69) in their right to maintain dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess/monitor one of three residents (R30) for self-administration of medication out of a total sample of 21 residents reviewed.

Inspectors wroteBased on observations, interviews, and review of records the facility failed the following related to [NAME] Program: facility failed to display [NAME] information in a public and accessible location, a department provided poster informing residents of their right to explore or decline community transition, and their right to be free from retaliation, regardless of their decision on transition. Failure includes 12 out of 12 residents (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) included in the sample list for December 2024 and January 2025 of residents that can be a part of the [NAME] program. This failure has the potential to affect 12 residents (R1, R6, R13, R25, R42, R47, R69, R98, R99, R103, R207, R307) in their right to exercise community transition given proper information.

Inspectors wroteBased on observations, interviews and records review, the facility failed provide privacy and confidentiality of personal information for one (R307) of four residents reviewed in a sample of 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to help a resident maintain their highest practical level by failing to provide consistent restorative therapy for one of three residents (R61) in a total sample of 21. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs. 02/04/25, 11:33 AM, R61 lying down on his bed, with his personal belongings within reach. R61 alert, responsive, and in no apparent distress. R61 states that this is the first time someone applied his splint in a very long time. R61 states that he understands now probably because the state agency is in the building. R61 reports that staff are supposed to come and exercise his legs, but staff do not do this. R61 states that staff do not come in to talk about restorative therapy or exercises. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R3, R30) residents reviewed for medication administration in a total sample of 21 residents reviewed, resulting in a 7.69% error rate. Findings Include: R3 has diagnoses not limited to: Type 2 Diabetes without complications, Hemiplegia and Hemiparesis Following Cerebrovascular disease, and overactive bladder. R3s' electronic medication administration record (eMAR) dated 02/01/2025 - 02/28/2025 documents: Metformin HCL 500mg- 1 tablet by mouth two times a day scheduled at 9:00 AM. On 02/05/2025, at 8:37 AM, surveyor observed that this medication was not given to R3 during the 9:00 AM medication administration pass with V17 (Licensed Practical Nurse/LPN). R30 has diagnoses not limited to: [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy and ensure night-time snacks were offered and served consistently in accordance with the facility's policy for one (R87) resident in a sample of 21. 02/05/25, 10:15 AM, during resident council meeting, R87 states that he does not receive or is offered the nighttime snacks consistently and he would like to receive them consistently. 2/6/25, 1:01 PM, V8 (Dietary Manager) states that if a resident is not diabetic, they get the graham crackers or peanut butter crackers and juice at night-time snack. V8 states that everyone is supposed to be offered a night-time snack. V8 continues to state we close at 7:30 PM at night. Before my aids leave, they take the snacks to the floors, and give them, on a tray or in a bag. They are given to the floor CNAs (certified nursing assistants). [...]

Inspectors wroteBased on review of records and interview the facility failed to accurately classify resident record on psychotropic medication consent form to 1 out of 1 resident (R37) for a total of 5 residents reviewed for psychotropic medication. This failure has the potential to affect 1 resident (R37) on psychotropic medication side effects. Consent was given with error in classifying psychotropic medication having different side effects for which the consent was given.

Inspectors wroteBased on interview and document review the facility failed to ensure resident is free from verbal abuse. This failure affected 1 ( R1) of 4 ( R1,R2,R3 and R4) residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse and mental anguish by staff and also failed to appropriately identify incident(s) of abuse. This failure affected one resident (R2) whose wrists were tied to their bed side rails using pillowcases by a facility nurse as an attempt to confine R2 in bed for the nurse's convenience. As a result, R2 experienced feelings of humiliation and despair as evidenced by being tearful as well as physical pain and discomfort in both wrists. Any reasonable person in this situation would feel humiliated and ashamed. This was identified as an immediate jeopardy which begin on 10/12/24 at 3:00pm when V6 RN (Registered Nurse) tied R2 with pillowcase to the bed side rails. V1 (Administrator) was informed of the immediate jeopardy and template was presented 11/25/24 at 2:17 pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to assure that residents are free of unnecessary physical restraint(s), failed to identify the specific medical symptoms warranting the use of physical restraint(s) and failed to obtain physician orders with medical justification for physical restraint(s). This failure affected R2 whose wrists were tied to the bed side by a pillowcase by a nurse with no physician order, no consent or resident permission, and no medical justification. Any reasonable person in this situation would feel humiliated and ashamed. This was identified as an immediate jeopardy which begin on 10/12/24 at 3:00pm when V6 (Registered Nurse) tied R2 to their bedside rails with a pillowcase. V1 (Administrator) was informed of the immediate jeopardy and template was presented 11/25/24 at 2:17pm. The immediate jeopardy was removed on 12/3/24 at 3:29 pm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that treatment cart and resident medication was not left at the bedside un-attended when not in visual proximity of the nurse and not in use to prevent tampering and accidental hazard. This failure affected R4 whose inhaler was left at bed side over bed-table visible to the hallway and treatment cart left unlocked and un-attended in the hallway. This has the potential to affect all the 39 residents residing on the 2nd floor of the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure that there was sufficient staff on duty to meet resident's needs. This failure affected R2 was known to need adequate supervision for trying to get out of bed without help and who was tied to bed rails due to facility short staffing. This failure has the potential to affect all 39 resident residing on the 2nd floor of the facility.

Inspectors wroteBased on interview and record review the facility failed to immediately report an alleged abuse for one three residents (R2) in the sample reviewed for abuse. This failure affected R2 who was tied up to the bedside rails with pillowcase and this was not reported to IDPH (Illinois Department of Public Health). This has the potential to affect all 39 residents residing on the 2nd floor of the facility.

Inspectors wroteBased on interview and records review, the facility failed to refer five (R2, R3, R4, R5, R6) of five residents reviewed for newly or possible serious mental disorders for Preadmission Screening and Resident Review (PASRR) Level I and II in a sample of five.

Inspectors wroteBased on interview and record review, the facility failed to provide wound treatments for 2 (R1,R4) of 3 residents who were reviewed for wounds. The facility failed to : 1. Provide wound treatment for R1's surgical site. 2. Develop skin care plan interventions for R1. 3. Ensure wound skin assessment and Braden scale assessment completed on weekly basis for R1. 4 Provide wound treatment as ordered by physician for R4. These failures resulted in R1 being admitted to the hospital on [DATE] for dehiscence of the wound to groin area and R4's wound dressing not being changed daily.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical and verbal abuse. This failure affected 2 (R1, R2) residents of 4 reviewed for abuse.

Inspectors wroteOn 03/19/24 at 10:48 AM V9 (Wound Care Nurse) stated, V8 (Infection Control Preventionist/Licensed Practical Nurse) is filling in for the nurse. I will not be assigned to the floor for the rest of the day. On 03/19/24 at 10:53 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) left the floor giving the medication cart keys to V9 (Wound Care Nurse) to continue passing the medications. On 03/19/24 at 11:53 AM Surveyor asked V9 (Wound Care Nurse) the meaning when the resident names appear pink on the computer screen. V9 responded, They just popped up. We have a 2-hour window to give the medication. On 03/19/24 at 12:17 PM V9 (Wound Care Nurse) stated, Once the residents name turns pink on the computer screen the medications are overdue. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy on storage of food and hand washing by not discarding expired food and staff not washing hands after handling dirty dishes and before handling clean dishes. These failures have the potential to affect all 112 residents receiving food prepared in the facility's kitchen. Findings Include: On 3/19/24 at 9:25 AM, observed V43 (Dietary Aide) and V22 (Cook/Dietary Aide) working in the dish room. V43 was breaking down dirty resident lunch trays scraping food debris from the trays into the garbage. At 9:28 AM observed V22 placed scraped dirty dishes in a rack before pushing the rack into the dish machine to be washed. Observed V22 move to the clean side of the dish machine and pull out the rack containing cleaned dome lids and plates from the dish machine and then placed them on an open cart to dry. [...]

Inspectors wroteOn 03/19/24 at 10:00 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) retrieved the green tray containing the blood glucose supplies, wrist blood pressure cuff and tympanic thermometer from the top of the medication cart then entered R76 room. V8 placed the blood pressure cuff on R76 left wrist and checked R76 temperature using the tympanic thermometer. V8 placed the green tray on R76 overbed table, retrieved the glucometer, glucose strip and alcohol wipe, checked R76 blood glucose with a reading of 196. V8 placed the glucometer back in the green tray then exited R76 room. On 03/19/24 at 10:04 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) placed the green tray with the glucometer, wrist blood pressure cuff and tympanic thermometer on top of the medication cart without cleaning them then began preparing R76 medications. [...]

Inspectors wroteBased on review of records and interview the facility failed to follow COVID-19 vaccination policy in offering, educating, and documenting COVID-19 for both staff and residents. These failures have the potential to affect residents (R72, R108, R117, R267) on receiving the benefits of COVID-19 vaccination and potential to affect all 112 residents taken care by facility staff that are not vaccinated.

Inspectors wrote2. R10 has diagnosis not limited to Paraplegia, Injury at Unspecified Level of Cervical Spinal Cord, Chronic Obstructive Pulmonary Disease, Chronic Pulmonary Embolism, Neuralgia and Neuritis, Lumbago with Sciatica, Anxiety Disorder, Major Depressive Disorder, Pneumonia, Myalgia, Acute Respiratory Failure, Depression, Cough, Dependence on Supplemental Oxygen and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. Care Plan document in part: Focus: R10 has altered respiratory status/difficulty breathing r/t (related/to) Anxiety, dx. (diagnosis) acute respiratory distress, oxygen dependence, morbid obesity with possible complications. Oxygen Settings: O2 via nasal canula. R10 Physician orders document in part: Oxygen Tubing Change Weekly and as Needed every night shift every Sunday. Oxygen Continuous at 2-3 Liters/min (minute) Via Nasal Cannula every shift. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and label medications and medication administration supplies according to standards as evidenced by expired medications, expired supplies, and refrigerated medications stored in unrefrigerated locations in two medication rooms observed out of three total medication rooms in the facility, and three medication carts out of a total of six medication carts in the facility. In addition, the facility failed to maintain crash carts in alignment with policy as evidenced by missing supplies, supplies in the wrong drawers, and expired supplies in three out of three crash carts in the facility.

Inspectors wroteBased on review of records and interviews the facility failed to follow policy in offering, educating, and documenting influenza and pneumococcal vaccinations to 4 of 5 residents (R72, R108, R117, R267) for a total sample of 5 residents reviewed for vaccinations. These failures have the potential to affect 4 residents (R72, R108, R117, R267) in determining their option by knowing and receiving the benefits of influenza and pneumococcal vaccines.

Inspectors wroteBased on observation, interviews, and review of record the facility failed to follow policy on maintaining privacy and dignity of a resident for 1 out of 2 residents (R267) for a total sample of 23 residents.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to protect the residents' right to be free from physical and/or mental abuse by resident (R47) against another resident (R64); failed to establish a resident sensitive and resident secure environment per abuse policy after physical abuse was determined. These failures affected 2 out of 23 residents (R64 and R47) right to be from abuse or the threat of abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to refer R74 to the state-designated authority for Level II PASRR (Pre-admission Screening and Resident Review) evaluation and determination after new onset of possible serious mental disorder for one out of a total sample of 23 residents.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide proper positioning for a dependent resident during mealtime. This deficient practice was observed for 1 (R17) resident reviewed for positioning in a sample of 23.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure low air loss mattress devices were on the correct settings for 1 dependent resident (R30) who is high risk in developing pressure ulcer and for 1 (R70) out of 2 dependent residents with current pressure ulcers in a final sample of 23 residents. Findings Include: On 3/19/24 at 10:40 AM R30's lying in bed alert and awake but confused. R30's low air loss mattress weight control knob was set between 350 pounds. At 10:45 AM, R70's lying in bed alert and able to verbalize needs. R70'a low air loss mattress weight control knob was set to 350 pounds. R70 stated R70 has wounds on R70's back and the staff do not reposition R70. R70's legs and hands were noted contracted. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed (a) to follow physician's order and ensure left hand splint was applied and in place and (b) failed to implement an individualized plan of care addressing the use of left hand split for 1 (R75) out of 3 residents reviewed for limited range of motion in a final sample of 23. Findings Include: R75's clinical records show an initial admission date of 8/7/23 with diagnoses not limited to paraplegia and muscle spasm. R75's Minimum Data Set (MDS) dated [DATE] shows R75 is cognitively intact and has impairment on one side of R75's upper extremity. R75's physician orders with active orders as of 3/19/24 shows an order that reads in part: Left Functional Splint. Apply after AM care for 6 hours as tolerated daily ordered on 1/30/24. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to disconnect and flush the gastric tube per physician order for a resident receiving enteral feedings. This failure has the potential for the gastric tubing to become clogged and malfunction for 1 (R50) resident reviewed for enteral feedings in a sample of 23. Findings Include: R50 has diagnosis not limited to Dysphagia, Protein-Calorie Malnutrition, Aphasia, Vitamin D Deficiency, Disorders of Plasma-Protein Metabolism, Gastroesophageal Reflux Disease and Gastrostomy. R50's Physician order document in part: in the afternoon related to Unspecified Protein-Calorie Malnutrition Jevity 1.5 @55ml (milliliter)/hr. (hour) continuous 18hrs: Up at 3PM and down at 9AM Total Volume 990ML. Enteral Feed Order one time a day related to Unspecified Protein Calorie Malnutrition Take down feeding. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to maintain an error rate of less than 5%. There were five medication errors out of 31 opportunities which resulted in a 16.13% medication error rate. Findings Include: On 03/19/24 at 10:00 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) retrieved the green tray containing the blood glucose supplies from the top of the medication cart then entered R76 room. V8 placed the green tray on R76 overbed table, retrieved the glucometer, glucose strip and alcohol wipe from the green tray, checked R76 blood glucose with a reading of 196. V8 placed the glucometer back in the green tray then exited R76 room. On 03/19/24 at 10:04 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) placed the green tray containing the glucometer on top of the medication cart then began preparing R76 medications. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered as prescribed for 2 (R63, R76) residents reviewed for significant medication errors during the medication administration observation. This failure has the potential to affect R63 blood glucose level and R76 blood glucose level and blood pressure. Finding Include: During medication administration V8 (Infection Control Preventionist/Licensed Practical Nurse) failed to administer R63 scheduled Humalog Insulin, and R76 scheduled Humalog insulin, Metformin 2 tablets, Furosemide and Enalapril. On 03/19/24 at 10:00 AM V8 (Infection Control Preventionist/Licensed Practical Nurse) retrieved the green tray containing the blood glucose supplies then entered R76 room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications did not exceed the time frame for medication administration for 5 (R8, R9, R34, R54, R63) of 7 (R63, R76) residents reviewed during medication administration. Findings Include: During medication reconciliation and review of the Medication Administration Audit Report dated 03/20/24 it was determined that the 09:00 AM scheduled medications were given outside of the facilities policies 2-hour window for medication administration. R34's Medication Administration Record document in part: 09:00 AM scheduled medications administered by V9 (Wound Care Nurse) include: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to obtain a physician's order prior to administering a urine drug screen and have a nurse conduct the screening for one (R74) out of a total sample of 23 residents reviewed for residents' rights.

Inspectors wroteBased on interview and record review, the facility failed to provide assistance in relocating one [R34] resident to another facility out of 23 residents in the sample

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate assistive device was provided for 1 (R34) out of 1 resident with history of multiple falls in a final sample of 23 reviewed for accidents and hazards. Findings Include: On 3/20/24 at 11:22 PM, R34 was observed sleeping in a geriatric chair in the 4th floor dining room. V20 (Licensed Practical Nurse) stated V20 is the nurse in charge for R34. V20 stated R34 was placed on the geriatric (Geri) chair because R34 is high risk for fall and tries to get up on his own. At 2:03 PM, V16 (Restorative Director) stated a Geri chair assessment needs to be completed before using for the resident. V16 stated Geri chair assessment is done if therapy determines the resident has poor trunk control. V16 stated R34 is high risk for falls. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to a.) ensure pain medications were ordered in a timely manner, b.) failed to maintain a sufficient supply and administer pain medication as ordered by the physician and c.) failed to document a prn (as needed) pain medication administration on the MAR (Medication Administration Record) for 1 (R10) resident reviewed for pain management. This failure resulted in R10 going multiple days without pain medications. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R1) remained free from physical abuse. This failure affected one resident (R1) out of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical abuse. This failure affected R5 who was physically pushed by R1, causing R5 to fall and sustained a left hip fracture required emergency transfer to the hospital with surgical repair of the left hip fracture and affected R7 who was physically punched in the face by R1 causing a periorbital contusion when reviewed for resident to resident, physical assault, in the sample of 4 residents (R1, R3, R5 and R7).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to keep R6 free from abuse. This failure resulted in R6 being sprayed in the face with a chemical agent by a staff member (V26). R6 experienced eye irritation and pain which required irrigation at the emergency department. The facility further failed to keep V26 away from R6 after the incident by allowing V26 to continue to work with R6 and allowed V26 to remain on the same unit. This situation was identified as an immediate jeopardy. The Administrator, Assistant Administrator-in-training, and the Director of Nursing were presented with the immediate jeopardy template on 1/5/2024 at 9:55 AM. The immediate jeopardy began on 11/15/2023 and removed on 1/12/2024. The facility presented an acceptable removal plan on 1/12/2024. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to have a nurse assess a resident (R1) immediately after a fall and notify the physician. This resulted in a delay of care for R1 who sustained a displaced fracture of the greater trochanter of the right femur (right hip fracture) from the fall. R1 required surgical intervention. This affected one of six residents reviewed for falls.

Inspectors wroteBased on interviews and record reviews, the facility failed to (a) carry out physician orders in a timely manner, (b) notify physician of delayed services and family's request for hospital transfer, and (c) administer the correct dosage for one (R5) of 12 residents reviewed for improper nursing care.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement appropriate measures to ensure adequate supervision for 2 residents (R1 and R2) out of 3 residents reviewed for supervision and use of illicit substances. As a result, R1 overdosed twice and R2 overdosed once.

Inspectors wroteBased on interview and record review, the facility failed to maintain a safe resident environment and protect residents from abuse for 4 of four residents (R1, R2, R3, and R4) reviewed for abuse in the sample of four.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow policy and procedures for Fall Prevention by not completing a fall risk assessment to determine fall risk factors and target approaches to reduce risks, on a quarterly basis, for 1 (R37) of 1 resident reviewed for falls out of a total sample of 26 residents. As a result of this failure, R37 fell on the ground on 12/7/22 while wheeling herself independently on a wheelchair and sustained a left clavicle fracture. Findings Include: On 4/4/23 at 1:09 PM, R37 was eating lunch in R37's room. R37 complained of left shoulder pain radiating to R37's left arm and hand. R37 stated that R37 broke R37's clavicle sometime last year due to a fall. R37 stated, I was wheeling myself in the wheelchair from my smoking break. My wheelchair got stuck in a dirt. It tipped over and I landed on my left side on the ground. [...]

Inspectors wroteBased on observations, interview and record reviews the facility failed to 1.) prepare food under sanitary conditions. 2.)failed to ensure that frozen meat have not been left to thaw at room temperature.3.) failed to date perishable items in the refrigerator. 4.)failed to routinely monitor food temperatures on the steam table by not logging the temperature in the food temperature logbook. 5.)failed to ensure that dishwasher draining pipeline is not leaking and 6.)failed to maintain cold food item at 41F or cooler. These failures have the potential to affect 124 residents living in the facility with 4 residents on Nothing by Mouth (NPO) for a total facility's census of 128 dated 4/4/23.

Inspectors wroteBased on observation, interviews, and record review the facility (a) failed to dispose of garbage properly in a contained dumpsters (b) failed to keep the dumpster area clean and free of garbage or waste to maintain a sanitary condition to prevent harborage and feeding of pest. These failures could potentially affect all 128 residents that reside in the facility as of census 4/4/23.

Inspectors wroteBased observations, interviews, and review of records the facility failed the following; related to infection prevention and control: Failed to follow policy in perform hand hygiene during bedside care from soiled to clean surfaces for 1 resident (R56). Failed to maintain linen bag off the floor. Failed to clean reusable equipment (blood cuff) used by 3 residents (R2, R49 and R105). The facilty also failed to follow Water management Program related to risk assessment of Legionella and other opportunistic pathogens. These failures have the potential to affect all 128 residents in preventing infections.

Inspectors wroteBased on review of records and interviews the facility failed to follow policy of Covid-19 testing for resident and staff having close contact or exposed to confirmed case of Covid-19. These failures have the potential to affect all residents on the same floor in preventing infections.

Inspectors wroteBased on review of records and interviews the facility failed to follow Covid-19 Vaccination policy related to determining facility staff and residents' vaccination status to offer Covid-19 Vaccination, and documentation of education provided to residents. These failures have the potential to affect all 128 residents in preventing infections.

Inspectors wroteBased on review of records, and interviews the facility failed to monitor staff (facility and contracted) vaccination status. And failed to develop policy and procedure to ensure that all staff are fully vaccinated for Covid-19. These failures have the potential to affect all residents on the same floor in preventing infections.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to 1.) identify presence of PICC (Peripherally inserted central catheter) line and provide needed care and services for one (R115) resident. 2.) follow the facility's policy for PICC line or midline to (a) change transparent dressing every 7 days for 3 residents (R115, R5, R108); (b) change transparent dressing as needed for one (R226) resident; (c) measure PICC line external catheter and record with each dressing change; (d) failed to flush PICC line or midline for four residents (R115, R5, R108, R226). 3.) failed to develop the comprehensive person-centered care plan for four residents (R115, R5, R108, R226) and 4.)failed to ensure the PICC lumen (Hub) port was cleaned prior to administering IV (intravenous) antibiotic medication for one (R108) resident. [...]

Inspectors wroteBased on review of records and interviews the facility failed to follow policy related to monitoring and recording in the immunization log as part of resident record influenza and pneumococcal vaccination for 4 out of 5 residents (R8, R53, R61 and R118) reviewed for immunization. These failures have the potential to affect 4 residents vaccination benefits.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 2 (R36, R104) residents call lights were within reach in a sample of 26. Findings Include: R104 has diagnosis not limited to Tracheostomy, Gastrostomy, Heart Failure, Ventricular Tachycardia, Generalized Anxiety Disorder, Major Depressive Disorder, Dementia Chronic Respiratory Failure and Encephalopathy. R104 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 09 indicating moderately impaired. R104 Care Plan document in part: Focus: At risk for falls related to assistance needed. Date Initiated: 02/10/23. Interventions: Make sure my call light/personal belongings are in reach. Date Initiated: 02/10/23. Focus: The resident has a communication problem r/t (related /to) Dysphagia Date Initiated: 02/13/23. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to revise a resident's (R91) comprehensive care plan after weight loss for 1 of 26 residents reviewed for care plans.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow a resident's (R25) comprehensive care plan and provide turning and repositioning every two hours or as needed for 1 of 26 residents reviewed for nursing care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper placement of the gastrostomy tube prior to medication administration and provide gastrostomy care per orders for 1 (R98) of 3 (R36, R104) residents with gastrostomy tubes reviewed in a sample of 26. Findings Include: R98 has diagnosis not limited to Gastrostomy, Protein-Calorie Malnutrition, Dysphagia, Gastrointestinal Hemorrhage, Adult Failure to Thrive and Gastro-Esophageal Reflux. Order Summary Report dated 04/05/23 document in part: Enteral Feed Order every shift related to Encounter for Attention to Gastrostomy Check placement prior to feeding, flushing, and medication administration. -Order Date- 05/16/22. Enteral Feed Order every shift related to Encounter for Attention to Gastrostomy Flush G-Tube with 60ml of water before and after medication administration -Order Date-05/16/22. [...]

Inspectors wroteBased on observations, interview and record reviews the facility failed to follow policy and procedure on oxygen administration (a) to check physician's order for liter flow and method of administration; (b) to ensure that oxygen tubing and humidifier bottle changed and dated for one (R66) resident in a sample of 26 reviewed for oxygen use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the comprehensive care plan to ensure pain patch was applied as ordered by the physician for 1 (R37) of 1 resident reviewed for pain management in a sample of 26. Findings Include: On 4/4/23 at 1:09 PM, R37 was eating lunch in R37's room. R37 complained of left shoulder pain radiating to R37's left arm and hand. R37 stated that R37 broke R37's clavicle sometime last year due to a fall. R37 stated, I was wheeling myself in the wheelchair from my smoking break. My wheelchair got stuck in a dirt. It tipped over and I landed on my left side on the ground. I'm supposed to get a pain patch on my left shoulder, but I never got it today. I'm supposed to get it every morning at 6 AM. It's the only thing that takes away the pain on my shoulder. It helps with my muscle pain. Now my pain is at 6. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the system used for acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was followed by staff for 1 of 3 medication carts reviewed. Findings Include: R94 has diagnosis not limited to Unspecified Convulsions, Mood (Affective) Disorder, Repeated Falls and Unspecified Intracranial Injury with loss of consciousness. R94 BIMS (Brief Interview Mental Status) Section C Cognitive Pattern BIMS (Brief Interview Mental Status) score of 07 indicating severe impairment. On 04/05/23 at 12:07 PM during the third-floor low medication cart review with V9 (Registered Nurse) it was observed that R94 Controlled Drug Receipt/Record/Disposition Form dated 03/10/23 document in part: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for 2 (R2, R49) of 6 (R71, R98, R108, R121) residents reviewed for medication administration resulting in a 6.9% error rate. Findings Include: R2 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting the Right Dominant Side, Cerebral Infarction, Essential (Primary) Hypertension and Intracranial Injury. R2 Administration History Report with administration date of 04/04/23 09:00 AM and the Medication Administration Record dated 04/01/23 - 04/30/23 document Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG as not given. R49 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting the Left Non-Dominant Side, Cerebral Infarction and Essential (Primary) Hypertension. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered as prescribed for 2 (R2, R49) residents reviewed for significant medication errors during the medication administration observation. This failure has the potential to affect R2 blood pressure and heart rate and R49 blood pressure. Findings Include: R2 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting the Right Dominant Side, Cerebral Infarction, Essential (Primary) Hypertension and Intracranial Injury. R2 Administration History Report with administration date of 04/04/23 09:00 AM and the Medication Administration Record dated 04/01/23 - 04/30/23 document Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG as not given. The next documented blood pressure was 130/70, pulse 86 dated 04/05/23. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) ensure medications were not left on top of the medication cart unattended, b.) ensure medications were properly labeled and stored and c.) remove and discard insulin stored in the medication cart that had been open and in use for more than 28 day in 2 of 3 medication carts reviewed for medication labeling and storage. Findings Include: On 04/04/23 at 09:29 AM V8 (License Practical Nurse) entered R105 room leaving the bottles with Miralax Powder 17 GM/SCOOP 17 gram, Thera-M Tablet (Multiple Vitamins-Minerals) and Loratadine Tablet 10 MG on top of the medication cart unattended. On 04/05/23 at 09:51 AM the fourth-floor high medication cart was reviewed with V15 (Licensed Practical Nurse). [...]