Elevate Care Chicago North

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise one resident (R16) who was at high risk for falls. This failure resulted in R16 falling to the floor and sustaining a subdural hemorrhage. This failure affected one resident (R16) reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff increased their monitoring of resident body temperatures during an extreme weather-related event which affected 7 residents (R1, R2, R3, R5, R6, R7, R9) of 8 residents reviewed for quality of care during a heat related emergency in a total sample of 28 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were assessed and identified as highly vulnerable during an extreme weather-related event which affected 16 residents (R10, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, and R28) of 28 residents reviewed for an extreme weather-related event in a total sample of 28 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders by failing to perform blood glucose monitoring before meals for one resident (R1) in a sample of four reviewed.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy related to prevention of potential abuse and reporting of abuse allegations for two (R2, R5) out of twelve residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to notify Department of Public Health regional office for an abuse allegation for two (R2 and R5) out of 12 residents reviewed for abuse. 1. R2's face sheet / admission record shows initial admit date on 12/4/17, with diagnoses not limited to Type 2 diabetes mellitus with diabetic neuropathy, Hypertensive heart disease, Primary osteoarthritis, Hypothyroidism, Major depressive disorder, Unspecified dementia, Anxiety disorder, Insomnia, Gastro-esophageal reflux disease, Hyperlipidemia. MDS (Minimum Data Set) dated 3/13/26 shows R2's cognition is moderately impaired. On 4/21/26 At 11:12 AM, R2 was alert and verbally responsive, Spanish speaking, and able to speak and understand simple English. Requested V28 (Housekeeping) in R2's room as a Spanish speaking interpreter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate medication administration by failing to verify the correct insulin dose prior to administration for one (R5) of three residents reviewed for medication administration. Findings Include:R5's clinical records show an admission date of 10/10/25. R5's order summary report, dated 4/21/26, reads: Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 12 unit subcutaneously one time only for DM [Diabetes Mellitus] for 1 Day. R5's progress notes dated 4/21/26 at 12:09 PM reads in part: [R5] blood sugar was checked-460, [V74] notified, ordered to give one time dose of 12 unit of insulin lispro. R5's care plan documents in part: (Date initiated 10/29/25) R5 has Diabetes Mellitus, on insulin. Diabetes medication as ordered by doctor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely wound care for one (R1) out of three residents reviewed for wound treatment. Findings Include: R1's Electronic Health Record/EHR shows she was admitted to the facility on [DATE], she is [AGE] years old, her Brief Mental Status shows she is severely impaired. She has diagnoses not limited to chronic respiratory failure with hypoxia, encounter for attention to tracheostomy, dysphagia oropharyngeal phase, encephalopathy, dysphagia following cerebral infarction, aphonia, and dependence on supplemental oxygen. On 1/29/26 at 10:34 AM, R1 was supine in bed, non-verbal, and she was unable to respond to interview. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff documented administration of medications after the medications were administered. This failure affected 1 (R1) resident reviewed for pharmaceutical services in the total sample of 8 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to residents who obtained and consumed alcohol in the facility for 5 of 10 residents ( R1,R2,R3,R4 and R5) of the sample. This failure resulted in an unsafe environment for the residents in the facility.

Inspectors wroteBased on interview, and record review, the facility to ensure two [R1, R2] of five residents sampled was free of abuse from an employee. These failures resulted in R1 sustaining swollen discolored lips and pain, and R2 experiencing increase in pain and mental anguish. Findings Include, 1. R1's clinical record indicates R1 is a seventy-one-year-old, admitted with hemiplegia, hemiparesis following cerebral infarction affecting right dominant side, dysphagia, type II diabetes, vascular dementia, major depression, abnormal posture, lack of coordination, abnormal posture, gait and mobility, essential hypertension. R1's Minimum Date Set [MDS] section [C] indicates R1 is moderately cognitively intact. MDS section [GG] indicates R1 requires maximum assist with ADL care, transfers, and mobility in bed with repositioning. R1's Care plan documents: On 6/6/25, R1 reported physical abuse. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement and maintain an effective abuse training program for one [V5] of three employees reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a resident's care plan and physician's order to keep head of bed up to 45 degrees for a ventilator dependent resident (R73); failed to closely monitor a resident receiving continuous oxygen and failed to follow physician's order to ensure a resident was receiving the correct oxygen flow rate for one resident (R118); and failed to date/label and maintain proper storage of oxygen nasal cannula tubing in a plastic bag when not in use for two (R91, R419) out of four residents reviewed for respiratory care in a final sample of 32. Findings Include: 1. R118's electronic health records documented R118 was admitted in the facility on 3/7/23, with diagnoses not limited to Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Dementia, and Depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were properly labeled and dated. These failures have the potential to affect all 130 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a visitor entering a contact isolation room was wearing proper personal protective equipment (PPE) for one resident (R67), and failed to ensure staff wore the proper PPE when providing care for 3 (R41, R72, R219) residents on Enhanced Barrier Precautions. These failures has the potential to affect 60 residents residing on the third floor, and 60 residents residing on the fourth floor. Findings Include: 1. R219 was admitted to the facility on [DATE], with diagnoses not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Acute Kidney Failure, Dependence on Renal Dialysis, Gastrostomy, Hypertensive Heart Disease, Shaken Infant Syndrome, Cerebral Palsy, Epilepsy, Abnormalities of Gait and Mobility, Polycystic Ovarian Syndrome, and Blindness, Both Eyes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided privacy during care for 1 (R219) resident observed for resident rights in a sample of 32. Findings Include: R219 was admitted to the facility on [DATE], with diagnoses not limited to Type 2 Diabetes Mellitus with Hyperglycemia, Acute Kidney Failure, Dependence on Renal Dialysis, Gastrostomy, Hypertensive Heart Disease, Shaken Infant Syndrome, Cerebral Palsy, Epilepsy, Abnormalities of Gait and Mobility, Polycystic Ovarian Syndrome and Blindness, Both Eyes. R219's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicates resident is rarely/never understood. On 05/13/25 at 12:08 PM, R216 was observed from the doorway in bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an specialized call light within reach for a resident with limited movement. This affected one (R56) out of six residents reviewed for call lights in a total sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to refer residents to the appropriate state designated authority for re-screening and Level II referral. This failure affects three residents (R17, R84, R93) out of five residents reviewed for Preadmission Screening and Annual Resident Review (PASARR) in a total sample of thirty-two. Findings Include: 1. R84's Minimum Data Set (MDS), dated [DATE], shows R84 is moderately cognitively intact. R84's face sheet shows she is [AGE] years old, initially admitted to the facility on [DATE] with diagnoses of bipolar disorder current episode depressed, severe with psychotic features. There is no documentation to show R84 was referred to the appropriate state-designated authority for Level 2 PASARR evaluation and determination. On 5/14/25 at 1:52 PM, surveyor asked V24 (Social Services Consultant) for a Level 2 PASARR screening for R84; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one to one feeding assistance and properly position a resident in bed consistent with the plan of care during meals. This deficient practice was observed for 1 (R28) resident observed during the dining task in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure communication assistive materials were readily accessible for a resident (R67) who speaks a foreign language, and failed to provide communication tools or communicate with one resident (R161) who has communication deficit out of three residents reviewed in a final sample of 32. Findings Include: 1. R67's clinical records show an admission date of 6/5/24. R67s Minimum Data Set, dated [DATE], shows R67's preferred language is Urdu. R67's communication care plan shows R67 presents with an alteration in ability to communicate related to speaking a foreign language. On 5/13/25 at 12:49 PM, R67 was observed in bed alert and verbally responsive. V37's (R67's Family Member) was at bedside, visiting. Surveyor attempted to interview R67 and V37. R67 stated, Urdu. No English. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Peripherally Inserted Midline Catheter care for 1 (R66) resident reviewed for Midline care and failed to manage one residents (R112) low blood pressure, for 2 of 7 residents reviewed for quality of care in a sample of 32. Findings Include: 1. R66 was admitted to the facility on [DATE], with diagnoses not limited to Cerebral Palsy, Rheumatoid Arthritis, Chronic Pain Syndrome, Depression, Anxiety Disorder, Urinary Incontinence, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Right Lower Extremity, Neuromuscular Dysfunction of Bladder and Anemia. R66's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. R66's Oder Summary report documents: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician order to ensure assistive device was applied to one (R118) resident with a left hand contracture for residents reviewed for limited range of motion in a final sample of 32. Findings Include: On 5/13/25 at 10:34 AM, R118's electronic health records show R118 was admitted in the facility on 3/7/23, with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Dementia, and Depression. R118's Minimum Data Set, dated [DATE], shows R118 is moderately impaired with cognition, and is dependent on staff's assistance on dressing, grooming, and personal hygiene. R118's physician order reads: Apply left hand palm protector at all times or as tolerated for contracture management. Check for skin irritation, redness and pain. [...]

Inspectors wroteBased on observation and interview, the facility failed to prevent urinary drainage bag from touching the floor for one (R57) out of three residents reviewed for urinary catheter in a sample of 32. Findings Include: R57 has diagnoses including but not limited to Benign Prostatic Hyperplasia, Obstructive and Reflux Uropathy, Hematuria, Chronic Kidney Disease Stage 3, Cognitive Communication Deficit, Weakness, and Abnormalities of Gait and Mobility. R57's MDS (Minimum Data Set) indicates R57 is cognitively intact and has an indwelling catheter. R57's Order Summary Report, dated 05/13/25, documents diagnosis for indwelling catheter: Obstructive Uropathy and change indwelling catheter and drainage bag as needed. On 05/13/25 at 12:18 PM, R57 was lying in bed, and urinary drainage bag was lying directly on the floor next to R57's bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine medications to one resident (R2) as ordered by the prescriber to meet R2's needs. This failure resulted in R2 having pain, vomiting, and diarrhea.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess one resident (R2) for self-administration of medications. This failure affected one resident (R2) reviewed for medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for 1 resident (R3) out of 3 residents reviewed for call lights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date the oxygen tubing per facility policy for two residents (R3 and R4) in a sample of three residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for eight (R1-R8) out of eight residents reviewed for homelike environment, with the potential to affect all the residents who reside on the second floor.

Inspectors wroteBased on interview and record review, the facility failed to provide timely incontinence care for two (R1, R5) out of seven residents reviewed for improper nursing care, with the potential to affect all the dependent residents V9 (Certified Nurse Aide) cares for in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care for four dependent residents (R1, R4, R5, R9) reviewed for improper nursing care.

Inspectors wroteBased on interview and record review, the facility failing to affirm the right of the resident (R2) to be free from physical abuse and to have a safe environment, resulting in R1 punching R2 in the face. This failure resulted in R2 crying, and R2 being afraid R1 would attack R2 again. Findings Include: R1's face sheet shows R1 has diagnoses including Schizophrenia and Unspecified Intellectual Disabilities. R1's Minimum Data Set (MDS), dated [DATE] and 12/22/24, shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) score of 15, and has the ability to walk. R1's behavior care plan documented: (dated initiated 3/21/2019) R1 displays behavioral symptoms related to severe mental illness. These are manifested by rummaging, or taking food off of food carts, or unattended food. R1 may become agitated when redirected and display aggressive behavior. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper and adequate care (oral hygiene, grooming and shower / hair wash) and develop an individualized plan of care for 1 (R3) resident who is dependent with care. These failures affected one (R3) of three residents reviewed for improper nursing care.

Inspectors wroteBased on interview and record review, the facility failed to follow a resident's care plan, failed to follow their seizures policy to assess and document findings and observations of a resident's seizure activity, and failed to send a resident to the hospital for further evaluation who got punched in the face and is on anti-coagulant therapy with active seizures. These failures affected one (R2) out of three residents reviewed for abuse. Findings Include: R2's face sheet shows R2 diagnoses including Hemiplegia Affecting Right Dominant Side, Vascular Dementia, Schizoaffective Disorder, Anxiety Disorder, Right Hand Contracture, and Epilepsy. R2's Minimum Data Set/MDS, dated [DATE], shows R2 has moderately impaired cognition with BIMS (Brief Interview for Mental Status) of 12, and requires substantial maximal assistance from staff with activities of daily living. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow R3's care plan to apply Bilateral Palm Protectors due to actual contracture. This failure affected one (R3) of three residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow R3's plan of care to ensure additional tracheostomy tube at bedside for an emergency. This failure could potentially affect one (R3) of three residents reviewed for improper nursing care.

Inspectors wroteBased on interview and record review, fthe acility failed to follow their policy to ensure safe mechanical lift transfers are practiced for one (R15) out of three residents in a sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food in the main cooler was discarded after the used by date, and failed to ensure frozen meat products were dated inside the main freezer. This failure has the potential to affect 122 residents in the facility who are receiving oral diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Enhanced Barrier Precautions while providing wound care to 1 (R137) resident; failed to post Enhanced Barrier Precautions (EBP) signage and have Personal Protective Equipment bin outside 1 (R93's room); and failed to provide enhanced barrier precautions to 1 (R143) resident with an indwelling medical device. This has the potential to affect all residents living in the facility. Findings Include: 1. R137's Face Sheet shows R137 is a [AGE] year-old, with Brief Interview for Mental Status (BIMS) score of 0 (05/11/24), which means R137 is cognitively impaired. Physician Order Sheet shows R137's diagnoses include Acute and Chronic Respiratory Failure with Hypoxia, Dependence on Renal Dialysis, Dependence on Respirator Ventilator Status, Encounter for Attention to Gastrostomy, and Chronic Pressure Wound. [...]

Inspectors wroteBased on interview and record review, facility failed to maintain resident personal fund accounting for five residents (R4, R22, R55, R138, R218) out of a sample of six residents (R4, R22, R55, R74, R138, R218). Findings Include: On [DATE] at 11 AM during Resident Council interview, R4 stated she used to get money each month, but now gets no money. R121 stated, Everyone has brought the money issue up. I feel entitled to money that I don't get. I get nothing. I spoke to the office. They said 'Well, maybe later, maybe next year'. R121 stated many residents have raised the issue of money and allowances. It comes up all the time. There has been no response from administration. R74 stated he feels that he is owed money that he is not getting. R121 stated the subject of money and allowances is a very horrible subject for people here. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to follow the residents comprehensive care plans to ensure communication boards/books were readily accessible at all times for 4 (R30, R63, R49, R71) out of 4 residents who speak foreign language in a final sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure reducing air mattresses were set according to the resident's weight for 5 (R75, R93, R134, R318, R418) of 8 (R27, R101, R571) residents reviewed for pressure ulcers in a sample of 34. Finding Include: 1. R75 has diagnoses not limited to Hyperlipidemia, Urinary Incontinence, Depression, Anxiety Disorder, Functional Quadriplegia, Urinary Tract Infection, Morbid (Severe) Obesity Due to Excess Calories, Cerebral Palsy, Chronic Pain Syndrome, Rheumatoid Arthritis and Ataxic Gait. R75's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15, indicating intact cognitive response. R75's Care Plan documents: Resident is at risk for alteration in skin integrity related to: Limited Joint Mobility, Overweight/Obesity R75's Order Summary Report documents: Low Air Loss Mattress in use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure their Central Supply Room to ensure it is inaccessible by residents and visitors. This failure has the potential to affect the 55 residents that are mobile about the facility. The facility also failed to ensure equipment that could cause a fire hazard was out of a resident's room for 1 (R78) out of a final sample of 34 residents reviewed for safety hazards. Findings Include: 1. On 6/04/24 at 10:36 AM, R78 was resting in bed alert and verbally responsive. Surveyor noted a black space heater by R78's bed that was turned on. R78 stated the facility provided the space heater to use. On 6/05/24 at 9:55 AM, Surveyor and V21 (Director of Environmental Services) entered R78's room and noted R78's space heater by R78's bed that was turned on. [...]

Inspectors wrote2. R133's admission Record documents in part medical diagnoses including but not limited to chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. R133's Order Summary Report documents in part active orders to change oxygen tubing and humidifier every night shift every seven days and as needed (ordered 4/25/2024). On 6/04/2024 at 9:59 AM, R133 was lying in bed and receiving oxygen via nasal cannula. The nasal cannula was not dated or labeled. Facility's Oxygen & Respirator Equipment-Changing/Cleaning policy, last revised 1/7/19, documents the nasal cannula will be dated with the date the tubing was changed. 3. On 6/04/24 at 12:11 PM, R35 was lying in bed alert and verbally responsive. R35's nebulizer machine was turned on, but R35 was not using it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Storage of Medications policy and store medications in locked compartments for 2 [R69, R107] residents on 2 of 5 medication carts and 1 of 4 medication storage rooms; failed to label individual resident's insulin [NAME] with an open/expiration date for 2 [R157, R571] residents; failed to follow their policy to discard expired insulin for 1 [R34] resident; and failed to follow pharmaceutical storage instructions to refrigerate unopened insulin for 2[R112, R157 ]in 1 of 5 medication carts reviewed for medication storage, in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date food items in resident personal refrigerator; failed to monitor and document personal refrigerator temperatures daily to ensure temperature is maintained at or below 41 degrees F (Fahrenheit) for safe food storage; failed to discard unlabeled/undated food or foods whose date is outside facility food storage policy of three days; and failed to clean personal refrigerators regularly to maintain a safe and sanitary environment for food storage. This has the potential to effect 4 residents (R23, R97, R105, R164) out of 7 residents reviewed for personal food storage in a total sample of 34.

Inspectors wroteBased on interview, and record review, the facility failed to follow a resident's (R53) preference for a shower schedule for one out of a total sample of 34 residents.

Inspectors wroteBased on observation, interview, and record review, facility failed to follow facility policy and standards of professional practice in documenting the code status of two residents (R31, R138); failed to educate one resident (R138) on Advanced Directives; and failed to engage the healthcare representative in the care of one resident (R138) out of 34 total residents in the sample.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident to the appropriate state designated authority for re-screening and Level II referral after admission extended beyond initial 30 days. This failure has the potential to effect one resident (R55) out of 2 residents reviewed for PASARR in a total sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure and the comprehensive care plan to ensure incontinence care was provided for a dependent incontinent resident in a timely manner for 1 (R2) of 2 residents reviewed for ADL (Activities of Daily Living) care in a final sample of 34. Findings Include: R2's clinical records show R2 has diagnoses not limited to Hemiplegia Affecting Right Dominant Side, Right Hand Contracture, and Vascular Dementia. R2's Minimum Data Set, dated [DATE], shows R2 is moderately impaired with cognition and require substantial/maximal assistance from staff with toileting. R2's comprehensive care plan shows R2 is incontinent of bowel and bladder with one intervention that reads: Provide pericare [perineal care] after each incontinent episode. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's bilateral splints were placed per the plan of care and update the care plan to reflect the resident preferences for 1 (R101) of 2 residents reviewed for positioning and limited range of motion in a sample of 34. Findings Include: R101 has diagnosis not limited to Quadriplegia, C5-C7 Incomplete, Quadriplegia, C1-C4 Incomplete, Moderate Protein-Calorie Malnutrition, Acute Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity, Autonomic Dysreflexia, Epilepsy, Hypertensive Heart Disease, Depression, Anemia, Neuromuscular Dysfunction of Bladder, Insomnia, Gastro-Esophageal Reflux Disease, Post-Traumatic Stress Disorder, Personal History of Sudden Cardiac Arrest, and Peripheral Vascular Disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent urinary drainage bag from touching the floor for one (R318) out of 1 resident reviewed for urinary catheter in a sample of 34. Findings Include: R318's diagnoses include Pressure Ulcer of Sacral Region Stage 4, Pneumonia, Type 2 Diabetes Mellitus with Hyperglycemia, Dilated Cardiomyopathy, Enterocolitis due to Clostridium Difficile Not Specified As Recurrent, Chronic Kidney Disease Stage 3B, Elevated [NAME] Blood Cell Count, Hypothyroidism, Peripheral Vascular Disease, Abnormalities of Gait Mobility, Unsteadiness on Feet, Unspecified Atrial Fibrillation, Hypertension, Embolism and Thrombosis of Other Specified Veins, Hyperlipidemia, Anemia, Slowness, And Poor Responsiveness. [...]

Inspectors wrote2. R108 has diagnosis not limited to Displaced Comminuted Fracture of Shaft of Right Femur, Traumatic Subdural Hemorrhage with Loss of Consciousness of 30 Minutes or Less, Type 2 Diabetes Mellitus with Hyperglycemia, Type 2 Diabetes Mellitus with Diabetic Nephropathy, Obesity, Anemia in Chronic Kidney Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Hypertensive Heart and Chronic Kidney Disease with Stage 5 Chronic Kidney Disease, Dependence on Renal Dialysis, Epilepsy, Dysphagia, Abnormalities of Gait and Mobility, Lack of Coordination, Abnormal Posture, Cognitive Communication Deficit, and Elevated [NAME] Blood Cell Count. R108's Order Summary Report documents: Nepro one time a day 1 carton for supplementation. Dialysis (Renal) Consistent Carbohydrate diet Regular texture. R108's Care Plan documents: Resident is on therapeutic diet. Nepro 1 carton qd (every day). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order and Dietary recommendation for feeding rate were followed for 1 (R418) out of 3 residents reviewed for enteral feedings in a final sample of 34. Findings Include: R418's clinical records show R418 was admitted on [DATE] and weighed 147.2 pounds. R418 has diagnoses not limited to Dysphagia and Dementia. R418's clinical admission form, dated 6/1/24 at 10:59 PM, shows R418 is comatose. R418's physician order shows R418 to receive enteral feeding of Nepro 1.8 at 70 ml/hr for 18 hours to infused 1260 ml total. This was ordered on 6/03/24. R418's Dietary Evaluation, dated 6/3/24 at 8:07 AM, shows R418 was assessed to be underweight and has pressure ulcers. V33 recommended for the enteral feeding to be increased at 70 ml/hr for 18 hours that will provide 33 kcal/kilogram. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow resident's food allergy and food preferences. This failure affected 1 (R143) out of 3 residents reviewed for nutrition in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate medical records for one (R148) out of a total sample of 34 residents.

Inspectors wroteBased upon record review and interview, failed to revise fall prevention interventions; failed to implement appropriate fall prevention interventions; and failed to provide supervision to one of four residents (R2) reviewed for falls. These failures resulted in R2 sustaining a fall, laceration (above the right eye), and stitches.

Inspectors wroteBased upon interview and record review, the facility failed to ensure that 1:1 feeding assistance was provided to three of three residents (R2, R3, R4) reviewed for nutrition. These failures resulted in R2 sustaining significant weight loss.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure adequate staff were available to meet the needs for four of four dependent residents (R2, R3, R4, R5) in the sample. This failure has the potential to affect a total of 114 residents residing on 1st, 2nd and 4th floor.

Inspectors wroteBased on record review and interview, the facility failed to inventory personal belongings and failed to locate and/or replace a reported missing watch for one of four residents (R2) reviewed for misappropriation/exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure (R5) was on the get up list and failed to provide ADL (Activities of Daily Living) care to two of three dependent residents (R3, R5) reviewed for ADL care.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure nursing staff are aware of required LALM (Low Air Loss Mattress) settings; failed to ensure LALM settings are correct (re: weight, mode); failed to follow the LALM operational manual; failed to ensure staff timely report skin integrity impairments; and failed to ensure staff turn/reposition dependent residents as needed for two of four residents (R3, R4) reviewed for pressure ulcers.

Inspectors wroteBased upon interview and record review, the facility failed to provide restorative services as directed for three of four residents (R2, R3, R5) reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately supervise 1 (R1) of 3 residents reviewed for elopement. This failure resulted in R1 leaving the facility unsupervised, sustaining a fall when he eloped from the facility, and R1 being taken to the hospital. R1 was diagnosed with a left foot fracture. This situation was identified as an Immediate Jeopardy. The Administrator was notified of the Immediate Jeopardy on 01/30/2024. The Immediate Jeopardy began on 1/5/2024, and was removed on 2/1/24. The facility presented an acceptable removal plan on 2/1/24. However, the deficiency remains out of compliance at the second level of harm until the facility evaluates the effectiveness of the removal plan.

Inspectors wroteBased on interview and record review, the facility failed to follow their policies and procedures to ensure residents received their medications according to the physician's order for 3 (R3, R4, R5) out of 3 residents reviewed for improper nursing care. Findings Include: 1. R3's clinical records show an initial admission date of 4/26/06, with listed diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Gastro-Esophageal Reflux Disease (GERD), and Stage 4 Chronic Kidney Disease. R3's Minimum Data Set (MDS), dated [DATE], shows R4 is cognitively intact. R3's POS (Physician Order Set) with active orders as of 1/28/24 shows the following physician orders: Omeprazole 20 MG by mouth for GERD, Advair Diskus inhaler for COPD, and Bacitracin-Polymixin ointment to both eyes. R3's MAR shows that these medications were not signed off as administered to R3 on 1/9/24 at 6:00 AM. On 1/28/24 at 10: [...]

Inspectors wroteBased on observation , interview, and record review, the facility failed to provide comfortable and safe temperature levels on 2 of 4 resident floors in resident occupied areas. (1st and 4th floors). This had an affect on the comfort of 8 residents (R1,R2,R3,R4,R5,R6,R7,R8) in a sample of 8 .

Inspectors wroteBased on observation , interview and document review, the facility failed to ensure each resident receives adequate supervision to prevent accidents in 4 ( R1,R3,R4 and R5 ) of 8 residents included in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent the development of a pressure ulcer or injury for a resident identified at risk; failed to document on the electronic treatment administration record (TAR) after each treatment for 1 (R2) resident with multiple acquired pressure ulcers; failed to revise the care plan to reflect alteration of skin integrity, approaches, and goals for care for 2 (R2 and R4) residents with multiple acquired pressure ulcers; and failed to provide specialty mattress for 1 (R4) resident with multiple acquired pressure ulcers. These failures affected 2 (R2 and R4) out of 3 residents reviewed for pressure ulcers. As a result of these failures, R2 developed a facility acquired stage III pressure ulcer to left ear, and a facility acquired stage IV pressure ulcer to coccyx / sacrum. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized fall risk measures in place prior to a resident sustaining a fall for a resident assessed as being at high fall risk upon admission; and failed to put new individualized fall risk interventions in place for each subsequent fall for one (R4) out of three residents reviewed for falls. This failure resulted in R4 sustaining a fall on 08/24/23, resulting in a left hip pinning for left displaced femoral neck fracture, and R4 also sustaining two additional falls on 09/21/23 and 11/13/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their weight policy, and failed to care plan a resident that sustained significant weight loss for 1 out of 3 residents (R5) reviewed for nutrition. These failures resulted to R5 experiencing significant weight loss that was not reported, addressed, or care planned.

Inspectors wroteBased on interview and record review, the facility failed to provide needed care or services and failed to establish plan of care to ensure a midline catheter was removed or discontinued that was not in used from 10/5/23 to 12/7/23 for 1 (R2) resident, in a sample of 3 residents reviewed for improper nursing care.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment or services by not ensuring a splint was applied to maintain range of motion (ROM) and to prevent further contractures to right and left ankle for 1 (R2) resident out of 3 residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the policy on preventive maintenance and inspection of a resident's room, with baseboard that has screws that are unsafe for 1 out of 1 resident (R5) reviewed for physical environment safety.

Inspectors wroteBased on interview and record, the facility failed to ensure that residents are free from staff to resident verbal and mental abuse for two of two residents (R1,R2) reviewed for abuse. This deficient practice resulted in R1 verbalizing feelings of anger and R2 demonstrating sadness.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse for two of two residents (R1, R2) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure diagnostic tests were performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care. This failure affected 1 (R1) of 3 residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Low Air Loss Mattress was set based on the resident' weight, and failed to ensure the Low Air Loss Mattress was set on appropriate mode. These failures affected 1 (R13) resident reviewed for pressure ulcer/injury prevention and treatment in the total sample of 16 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to a.) ensure food items were properly labeled, dated, and stored, b.) clean walk-in refrigerator ceiling, c.) allow service ware equipment to air dry before using. These deficient practices have the potential to affect all 130 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow call light policy to ensure call light is within easy accessibility to the resident at the bedside. This failure affected 6 (R34, R86, R130, R148, R156, R161) residents reviewed for accommodation of needs in a total sample of 38 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow user manual operating instructions to maintain appropriate setting of low air loss mattress for 9 (R12, R30, R64, R70, R105, R123, R137, R173, R223) residents. This failure affected 9 (R12, R30, R64, R70, R105, R123, R137, R173, R223) residents reviewed for pressure ulcer in a total sample of 38.

Inspectors wroteBased on observation, interview and record review, the facility failed a.) to provide G (Gastrostomy) -Tube care and G-tube dressing changes as ordered for four (R116, R118, R120, R173) residents, b.) follow the gastrostomy tube feeding policy to follow physician's order for the type of formula administered for three residents (R12, R118, R372) residents, c.) label G-tube feeding formula containers for two (R118, R159) residents and d.) follow the enteral feeding administration physician orders for one (R116) resident. This failure has the potential to affect seven (R12, R116, R118, R120, R159, R173, R372) out of eleven (R123 R151, R160, R226) residents reviewed for tube feeding in a total sample of 38. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow facility policy and procedure for labeling, dating, and changing oxygen and respiratory care equipment for four residents (R25, R73, R92, R100) and failed to develop care plan for R92's oxygen use in a total sample of 38 residents reviewed. Findings Include: On 07/18/23 at 11:35 AM, observed R100 lying in bed with nebulizer mask sitting on top of bed side table with tubing attached. Nebulizer mask and tubing was not in a bag or container and no bag or container was seen near or around R100's bed or table. The Nebulizer mask and tubing was not observed to be dated. Also, observed oxygen concentrator next to R100's bed with a humidifier bottle filled with water in it dated 09/19/22. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to (a) double-lock controlled substances, (b) discard expired and loose medications, (c) ensure medications remained in their original packaging, (d) ensure only authorized staff had access to the keys for the medication storage areas, (e) label insulins with open dates, and (f) ensure a medication cart was clean to prevent contamination for 2 of 2 medication rooms and 3 of 4 medication carts reviewed for medication storage and labeling.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to practice proper hand hygiene during medication administration for R140 and during wound care treatment for R2 and failed to follow their policy and procedure to ensure proper personal protective equipment (PPE) were used during high contact resident care activities for 4 (R2, R116, R118, R120, R151) of 8 residents reviewed for infection control and prevention in a total sample of 38. Findings Include: On 7/18/23 at 11:39 AM, V10 (Treatment Nurse) was about to perform wound care treatment for R2. R2's door has a signage indicating R2 is on an Enhanced Barrier Precaution. The following was observed during R2's wound care observation: V10 was not wearing gown and with her gloves on entered R2's room to start wound care treatment. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal and influenza vaccinations and assess eligibility and offer pneumococcal vaccination to five (R2, R67, R70, R85, R322) of six residents reviewed for pneumococcal and influenza vaccinations. Findings Include: 1. R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: paraplegia, chronic obstructive pulmonary disease, obstructive sleep apnea, and heart failure. R2's current physician orders with active orders as of 7/19/23 revealed Pneumococcal Vaccine Unless Contraindicated. Record in Immunization Tab. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine to 4 (R67, R70, R85, R322) of 6 residents reviewed for COVID-19 vaccinations in a total sanple of 38 residents. Findings Include: On 7/18/23 at 3:30 PM, V3 (Infection Preventionist) stated that all COVID-19 vaccines information for the residents, their consents, and education should be in the resident's electronic health record. V3 stated, I don't have anything in paper. V3 stated that V3 has an immunization log that V3 just initiated since V3 started in February of this year as the Infection Preventionist, but V3 does not have any of the residents' COVID-19 vaccination consents and education provided. On 7/19/23 at 9:34 AM, R67, R70, R85, and R322's electronic health records (EHR) were reviewed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's dignity was maintained by not providing privacy during incontinence care for one resident (R151) reviewed for dignity in a total sample of 38 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the resident's bilateral hand mittens restraint at least quarterly to determine if restraint is still appropriate and warranted, failed to follow physician's order to release restraint at least every two hours (for meals) for 1 (R85) of 1 resident reviewed for restraints in a total sample of 38 residents. Findings Include: On 7/18/23 at 10:28 AM, R85 was quietly sleeping in bed noted with bilateral hands mittens. At 10:31 AM, V4 (Licensed Practical Nurse) stated that R85 was applied with the mittens for both hands because R85 has behaviors of pulling R85's dialysis catheter. At 12:44 PM, V12 (Certified Nursing Assistant) was feeding R85 in R85's room. R85 was calm and cooperative. R85 was noted still wearing mittens to both hands. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow standards of practice for medication administration for 1 (R136) out of 4 residents reviewed during medication pass.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure an accurate controlled substance record for a resident (R85) in 1 out of 4 medication carts reviewed.

Inspectors wroteBased on interview, and record review, the facility failed to follow policy for psychotropic medication: 1. Failed to obtain consent of psychotropic medication use for 1 (R161) resident. 2. Failed to ensure that care plan is develop with suitable goals and approaches related to use of psychotropic drug for 1 (R161) resident. 3. Failed to ensure that residents who use psychotropic medication shall receive gradual dose reductions for 2 (R64 and R161) residents. 4. Failed to ensure that as needed (PRN) antianxiety medication shall not be use used beyond 14 days for 1 (R161) resident. These failures affected 2 (R64 and R161) of 2 residents reviewed for unnecessary medications in a sample of 38.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that their medication error rate was less than five percent for 2 (R43, R136) of 4 residents observed during medication pass. Three errors during 27 opportunities for errors during medication pass. This resulted in a medication error rate of 11.11 percent.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident (R136) was free of any significant medication error for 1 of 4 residents reviewed during medication pass.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the pureed menu spreadsheets for three residents (R40, R48, R166) out of 17 residents receiving a pureed diet consistency in a total sample of 38 residents. Findings Include: On 07/19/23 between 9:07-9:45 AM, observed V19 (Head Cook) prepare pureed food items for lunch. V19 did not prepare pureed dinner roll. On 07/19/23 at 9:47 AM, V7 (Food Service Director) stated the pureed diets get the same food items as the residents on regular consistency diets except they receive those items in pureed form. On 07/19/23 at 11:19 AM, during lunch tray line service observed pureed diets being served pureed pork, pureed Cheesy Hashbrown Casserole, pureed baked beans, and pureed lemon pie. There was no pureed dinner roll prepared or served. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure accurate medical records for 1 (R136) resident out of a total sample of 38 residents.