Nexus at Palos

Inspectors wroteBased on interview and record review, the facility failed to follow its policy regarding notification of changes in resident condition by failing to notify the physician and/or nurse practitioner of a resident's new complaint of pain and inability to bear weight on the right lower extremity. This affected one of three residents reviewed for change in condition notification. The failure resulted in a delay in assessment and treatment of an undiagnosed right hip fracture. This failure affected one (R3) of three residents reviewed for notification.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate nursing care and follow physician recommendations by failing to obtain a right hip x-ray after a Resident experienced a fall and subsequently exhibited redness to the right hip. This deficient practice affected one of three residents reviewed for improper nursing care. This failure resulted in a delay in diagnostic evaluation, assessment and treatment of a injury. Following a change in condition, R3 was transferred to the hospital, where diagnostic imaging revealed a right hip fracture.

Inspectors wroteBased on interview and record review, the facility failed to follow its pain management policy by failing to adequately assess, monitor, and manage pain for one of three (R3) reviewed for pain management. This failure resulted in R3 following a fall, experiencing ongoing right lower extremity pain that was not comprehensively evaluated or effectively managed. This resulted in R3 experiencing unmanaged pain, an inability to fully participate in therapy services.

Inspectors wroteBased on interview and record review, the facility failed to follow their death of a resident policy by not having a registered nurse verify and timely pronounce the death for one resident. This affected one of one residents (R11) reviewed for death. This failure resulted in R11 being left on the ventilator and waiting almost two hours until police and emergencies services arrived to pronounce R11 death. Findings Include:R11 was admitted to the facility on [DATE] with a diagnosis of respiratory failure dependence on ventilator, tracheostomy status, seizures, and pneumonia. R11'a practitioner order for life sustaining treatment form (POLST) dated [DATE] documents: Do Not attempt Cardiopulmonary Resuscitation (CPR). R11's progress notes dated [DATE] at 10:25PM (22:25) documents: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its discharges policy and notify the family/emergency contact that R5 was being transferred to the hospital and the reason for the transfer. This affected one of three residents (R5) reviewed for notification of a change and Hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to follow its Rapid Response Policy and hospital discharge orders for one resident (R13) who experienced seizure-like activity by failing to initiate a rapid response, obtain a blood glucose reading, remain with the resident until emergency medical services (EMS) arrived, and monitor blood glucose levels following a hypoglycemic event. These failures affected 1 of 3 residents reviewed for quality of care.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its medication administration policy and check the administration record prior to administering a discontinued medication (Keppra - antiseizure medication) to one resident (R1) out of three reviewed for medication administration in a sample of 19.

Inspectors wroteBased on interviews and record review, the facility failed to supervise R1 who was diagnosed with Mild Dementia with moderate cognitive impairment, who was identified as incapable of unsupervised outside pass privileges, scored as high risk for elopement with exit-seeking behavior from leaving the facility unauthorized via an unknown exit/egress door, crossing a busy intersection, getting lost on a pace bus traveling approximately twelve miles to 95th and the [NAME] which is a high-traffic, multi-lane intersection with significant vehicle volume that includes access points to a major expressway (The [NAME] Expressway (I-90/I-94) is a11.47-mile, 8-to-16 lane, heavily traveled artery in Chicago, carrying over 300,000 vehicles daily from downtown to the South Side) for 1 of 3 residents reviewed for elopement in a total sample size of six. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy by not reporting alleged allegations of abuse for 1 of 1 (R4) residents within 2 hours reviewed for abuse reporting.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a dignified dining environment for one resident (R3) in a sample of 10 residents reviewed for resident rights.

Inspectors wroteBased on observation, interview and review record, the facility failed to ensure one resident (R3) was provided with a working call light in a sample of 10 residents reviewed for accommodations of needs.

Inspectors wroteBased on interview and record review the facility failed to administer medications as ordered by the physician for one resident (R3) in a sample of 10 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to change soiled gloves and failed to perform hand hygiene after providing incontinence care for one resident (R3) in a sample of 10 residents reviewed for incontinence care.

Inspectors wroteBased on interview, and record review the facility failed to provide a safe and orderly discharge for one of one resident (R9) reviewed for discharge. This failure resulted in R9 having to visit the local emergency room hospital for Dialysis treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure that a safe discharge and transfer, was provided and the resident receive the correct medication for one of one resident (R9) reviewed for discharge.

Inspectors wroteBased on interview and record review, the facility failed to follow physician order for Bilevel Positive Airway Pressure (Bipap) machine usage affecting one (R2) of three residents reviewed for physician orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure facility's daily nurse staffing information form posted at the front desk. This failure has the potential to affect 164 residents receiving care in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall care plan interventions for residents at risk of falls. This applies to 2 of 2 residents (R3 and R6) reviewed for fall in a sample of 9.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an inner canula to the tracheostomy for one resident (R6) during tracheostomy care. This failure affected one (R6) of three residents reviewed for tracheostomy care.

Inspectors wroteBased on interview and record review the facility failed to ensure two staff member were at bedside during incontinence care for one resident who was high risk for falls and required two person assistance with turning and repositioning. This affected one of three residents (R4). This resulted in R4 sustaining a fall, being transferred to the local hospital with a diagnosis of scalp hematoma.

Inspectors wroteBased on interview and record review, that facility failed to provide incontinence care for a resident who was identified as dependent on staff for toileting for over four hours. This affected one of three residents (R2) reviewed for incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to implement respiratory care interventions including ensuring the application of hand mitten restraint as ordered, and to maintain patency of trach tubes due to resident history of chronic pulling of tracheostomy tube according to the plan of care for 1 of 3 (R4) residents reviewed for tracheostomy care. As a result of the facility's noncompliance with mittens not being applied and monitored by staff, R4 was able to reach her tracheostomy tubing and self-decannulated which led to her expiring. [...]

Inspectors wroteBased on the interview and record review, the facility failed to follow its abuse policy by having residents lose their bank cards and state IDs. This applies to 3 of 3 residents reviewed (R3, R4, and R2) for misappropriation of resident property in a sample of 9 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Fall Prevention and Management Guidelines by not implementing fall prevention interventions in place for high-risk fall residents. This applies to 2 of 2 residents (R1 and R5) reviewed for fall.

Inspectors wrote2. R111 diagnoses include but are not limited to fracture of lumbar vertebra, diabetes, protein calorie malnutrition, and attention to gastrostomy. R111 is not verbally or physically responsive when spoken to or while staff providing care. On 05/14/25 at 10:35 AM V15, CNA, said, I check and change R111 every 2 hours. We check and change everyone every 2 hours. On 05/14/25 at 12:53 PM V30, wound nurse, accompanied surveyor to see R111. R111 in his bed laying mostly on his right side. R111's right ear was resting on his shoulder and pillow. A visible 4x4 foam dressing was over his left ear. V30 said R111 has deep tissue injuries to his left ear, elbows, sacrum, ischium, feet, and left lateral neck/head areas, skin tears and lacerations over his right hand. V30 said interventions for pressure relief include a horse shoe shaped neck pillow, heel boots, and an air mattress set to his weight. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and implement effective interventions for one resident at risk for malnutrition. This affected one of three residents (R113) reviewed for weight loss. This failure resulted in R113 sustaining a 34.8 percent unplanned weight loss in less than 6 months.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to discard expired intravenous fluid, house stock and resident specific medications; failed to ensure open date and expiration dates were labeled on multi-dose insulin and tuberculin vials; and failed to ensure residents medications were stored per policy in the medication room, medication cart and medication refrigerator. This affected four of four residents (R4, R74, R75, R452) reviewed for medication storage and labeling.

Inspectors wroteBased on interviews, observations, and records reviewed the facility failed to implement their policy for contact isolation precautions for residents with positive multidrug resistant organisms and failed to clean the Glucometer between resident use for blood sugar checks. This affected ten residents (R13, R52, R99, R123, R148, R152, R153, R48, R133, R154) in the total sample all reviewed for infection control practices in the sample.

Inspectors wroteBased on interview and record review, the facility failed to follow their change of condition policy by not immediately notifying the physician or nurse practitioner of a white patches in the mouth and on the tongue for one resident for two days. This affected for one of three (R352) residents reviewed for notification.

Inspectors wroteBased on interview and record the facility failed to refer a resident with serious mental illness for preadmission screening level 2 for two of two residents (R29 and R83) reviewed for appropriate PASRR screening.

Inspectors wrote2. On 05/13/25 at 11:21AM R148 said, I haven't' had a shower since before being in the hospital. I would really like a shower. I had my hair washed by the beauty shop, nearly 2 weeks ago. R148 looks oily and clumped together. R148 said, I would like a shower, I would not refuse one. V55, R148's son, present during interview and said she could be bathed or washed more or better. R148 cognition assessment dated [DATE] identifies a score of 15, cognitively intact. 5/15/25 at 11:47AM V56, CNA, was asked if she gave R148 a shower. R148 said, I don't really remember who she is, I don't work that side often. If they refuse a shower, we document it. I may have given a bed bath. We document bed bath or shower and give the shower sheet to the nurse. 5/15/25 11:51 am V57, CNA, said, We know who our shower is by the green binder. Showed the surveyor the binder. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the plan of care for assistance with hygiene for a dependent resident. This affected one of three residents (R57) reviewed for activities of daily living for dependent residents. Findings Include: On 5/13/25 at 10:44am R57 was observed resting in bed, alert. R57 observed with long beard hair, unkept. R57 said the staff is always busy, so he has been shaved. R57 said he would like his beard shaved. R57 said he does not want his hair cut. R57 said he does not know when the last time he was shaved. R57 said his nails needs to be cut down also. R57 said they staff are too busy. R57 said he cannot shave himself. On 5/14/25 at 10:56am R57 observed with long beard hair, unshaved. On 5/15/25 at 10:30am R57 observed with long beard hair, unshaved, and nails observed long and unclean. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders and provide a Bipap machine for 5 days for a resident diagnosed with obstructive sleep apnea, and chronic respiratory failure for one of one resident (R13) reviewed for following physician orders.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe home like environment and ensure that a power strip was not resting in the bed for one of one resident (R57), reviewed for safe home environment.

Inspectors wrote2. R3's face sheet shows diagnosis of anxiety, and major depression. R3 MDS dated [DATE] section I for mood disorders shows diagnosis of anxiety, and depression. Section A for identification information, A1500 denotes is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No is checked. 3. R83's face sheet shows diagnosis of anxiety, and major depression. R83 MDS dated [DATE] section I for mood disorders shows diagnosis of anxiety, and depression. Section A for identification information, A1500 denotes is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No is checked. 4. R65 face sheet shows diagnosis of anxiety, and major depression. [...]

Inspectors wroteBased on interview and record review, the facility neglected to follow their policy and procedure to ensure staff provided incontinence care at least every two hours for a resident identified as dependent on staff for toileting. This affected one of three (R131) residents reviewed for neglectful care and services. This failure resulted in R131 being exposed, soiled with feces, crying, verbally distraught, begging for help and feeling uncomfortable. Findings Include: R131 was diagnosis with mixed/urinary incontinence, rash and other nonspecific skin eruption, malignant neoplasm of vulva and obesity. Minimal Data Set (MDS) section C (cognitive patterns) dated 5/8/25 brief interview for mental status documents a score of thirteen which indicates cognitively intact. Section GG (functional abilities) documents R131 was dependent with toilet hygiene (helper does all of the effort). [...]

Inspectors wrote2. R59 has diagnoses with Dementia, history of falling and unspecified fracture of left humerus shaft with routine healing. Brief interview for mental status dated 3/6/25 documents a score of eight which indicates moderate cognitive impairment. Fall risk evaluation 2/27/25 documents score of twelve. Scoring a ten of higher makes resident high risk for falls. Minimal data set dated [DATE] documents: roll to left and right; R59 requires substantial/maximal assistance (helper does more than half the effort), lying to sitting on side of bed: R59 is dependent. On 5/14/25 at 3:15pm, R59 who was alert to self only said, she fell out of bed but could not elaborate on the events prior to the fall. On 5/14/25 at 3:22pm, V22 (nurse) said R59 had two unwitnessed falls from the bed. R59 was observed on the floor face down both times. V22 said she was not sure how R59 fell. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications in a timely manner and ensure a resident's linens were clean. These failures affect one of three (R8) residents reviewed for quality of care in total sample of eight residents.

Inspectors wroteBased on interview and record review the facility failed to prevent skin breakdown for a resident that drools for 1 of 3 residents (R2) reviewed for quality of care in the sample of 5.

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to follow their policy to answer resident call lights and provide assistance as soon as possible, including toileting and hygiene needs. This affected three (R8-R10) of three residents reviewed for call lights. This resulted in R8 waited 29 minutes after her request to be changed.

Inspectors wroteBased on observations, interviews and records reviewed the facility failed to follow their transmission based isolation precautions and enhanced barrier precautions for one resident with a multidrug resistant organism by not wearing a gown while administering medication via gastric tube. This failure affected one of three (R4) residents reviewed for transmission based precautions.

Inspectors wroteBased on interview and record review, the facility failed to prevent one resident (R3) who was admitted to the facility with healed scar tissue to sacrum and identified as moderate risk for skin breakdown from developing a facility acquired pressure ulcer measuring 2 centimeters (cm) length X 1.5cm width x 0.3cm depth within three days after admission for one of three residents reviewed for wounds. Findings Include: R3 diagnoses include paraplegia, moderate protein-calorie malnutrition, diabetes and osteomyelitis in the left foot. Brief interview for mental status dated 9/13/24 documents a score of fourteen which indicates cognitively intact. R3's face sheet documents: admission date 9/6/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not reporting one resident's (R1) final abuse investigation results within five days to the Illinois department of public health for one of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their mechanical lift policy by not utilizing two staff member to transfer one resident (R1) with a mechanical lift. This failure resulted in R1 hitting his head on the mechanical lift causing facial swelling around right eye for one of three reviewed for transfers.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its psychotropic medication policy and obtain informed consent from the resident and/or resident's family member prior to initiating a psychotropic medication. This failure affected one resident (R4) out of four reviewed for medications in a sample of 12.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its medication administration policy and notify the physician of a medication not available from the outside pharmacy, failed to obtain an alternative medication to prevent a resident from missing any scheduled medication dosages, and failed to accurately document the medication was not administered in the resident's MAR (medication administration record). This failure affected one resident (R4) out of four residents reviewed for accuracy of documentation in the resident's electronic medical record in a sample of 12.

Inspectors wrote1. Based on observation, interview, and record review, the facility failed to find appropriate roommates for R1, appropriately notify R1 of room change and consider room preferences and follow up with R1's discharge planning. This resulted in R1 being placed in a room with two residents (R11 and R12) that have behaviors and are severely cognitively impaired causing R1 to lose sleep and experience mental distress.

Inspectors wroteC. Based on interview and record review, the facility failed to immediately assess and call 911 for transfer of a resident with active seizures to the hospital. This failure affected one (R4) of three residents reviewed for change in condition and resulted in R4 having active seizure activity for three hours before 911 was called for resident to receive emergency treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a ventilator care unit had uninterrupted nursing supervision on [DATE]. Due to this failure, the unit was left in the care of unlicensed staff and (R3) experienced cardiac arrest while the two assigned nurses were on break outside of the facility.

Inspectors wroteBased on interview and record review the facility failed to implement abuse prevention protocol by failure to investigate and report allegation of resident mental abuse by an employee. This deficiency affects one (R1) of three residents reviewed for Abuse Prevention Program.

Inspectors wroteBased on interview and record review the facility failed to administered medication in accordance with the written orders of the attending physician. The facility failed to complete a medication error incident report for an omitted antibiotics medication. This deficiency affects one (R1) of three residents reviewed for Administration of Medications.

Inspectors wroteBased on observation, interview and record review, the facility failed follow sacrum treatment orders as prescribed, and failed to follow their plan of care for turning and repositioning and not placing an extra linen under residents. This affected one of three residents (R5) reviewed for pressure ulcer prevention. This failure resulted in R5 sitting a dialysis chair for over eight hours in pain, getting upset, feeling angry despite his request to be placed back in bed, this also resulted in R5 laying on a mechanical lift sling for over two hours. Findings Include: R5 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction, type II diabetes, acquired absence of left leg below the knee and right leg above the knee amputations. R5's Braden score dated 9/11/24 documents a score of 14 which indicates moderate risk for skin breakdown. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor one high risk for skin breakdown resident (R1) with a history of pressure sores who was admitted to the facility with skin intact for blanchable redness to sacrum. This affected one of three resident (R1) reviewed for pressure sores. This failure led to R1 developing an unstageable wound measuring 4 x 3cm within 12 days of being admitted to the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement new and effective fall interventions after a fall for one high fall risk resident (R11) with a diagnosis of dementia and history of falls. This affected one of three residents (R11) reviewed for fall and fall prevention. This failure resulted in R11 sustaining another unwitnessed fall a week later that required a hospital stay with 6 staples to the left side of the head.

Inspectors wroteBased on interview and record review, the facility failed to prevent an incident of staff to resident abuse for a resident assessed to be at risk for abuse. This affected one of three residents (R4) reviewed for abuse. This failure resulted in V6 (certified aid) calling R4 a mother f**cker and pushing R4 onto the bed and R4 bumping his head on the wall. Using a reasonable person concept, R4 would have felt scared, victimized, intimidated and unsafe. Findings Include: R4 was diagnosis with anxiety and depression. R4 care plan dated 2/16/24 documents: patient is at risk for abuse and neglect related to being in a skilled rehab facility. Minimal data set section C (cognitive patterns) dated 5/14/24 documents a score of eight which indicated moderately impaired. On 8/21/24 at 3:27 pm, V5 (CNA) said, the incident with V6 (CNA) and R4 started in the dining room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provided incontinence care for one resident(R9) who was identified as dependent on staff for toileting for more than 2 and half hours for one of three residents reviewed for incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to follow hospital discharge medication order and ensure that Temozolomide (TMZ, Chemotherapy Medication) was discontinued on 02/22/2023. This affects one resident of three residents (R7) reviewed for hospital discharge instructions. This failure resulted in R7 receiving 8 additional dosages of a chemotherapy (Temozolomide) medication. Findings Include: R7 was with diagnoses of but not limited to non-Hodgkin lymphoma, extra [NAME] and solid organ sites. admitted in the facility on 2/22/23. R7 has an order of Temozolomide 140mg by mouth one time a day along with Temozolomide (TMZ, Chemotherapy Medication) 180mg for a total of 320mg, with an order date of 2/22/23 and start date of 2/23/23. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for adequate housekeeping by not ensuring resident rooms and medical equipment were cleaned thoroughly and in a timely manner, not ensuring resident's rooms were free of clutter, not ensuring a resident's mattress was replaced when heavily soiled, and not ensuring a resident's meal tray was removed timely. This failure applied to six of seven residents (R1, R7, R11, R13, R14, and R21) reviewed for environment.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedure for providing assistance with activities of daily living by not ensuring a resident's nails were cut, not ensuring resident's received timely incontinence care, not ensuring resident's call lights were answered timely and were always accessible, not ensuring resident's consistently received bathing or showers and are free of odors, and not ensuring a resident who is dependent on staff for assistance was cleaned, dressed, and gotten out of bed. This failure applies to seven of eight residents (R1, R6, R7, R8, R11, R13, and R14) reviewed for activities of daily living.

Inspectors wroteBased on observations, interview, and record review the facility failed to perform hand hygiene between gloves changes, during wound care; failed to change PICC line dressing weekly; failed to change suction canister weekly; failed to date oxygen tubing; and failed to use personal protective equipment during care for a resident on contact isolation. This failure applied to three (R7, R15, and R16) out 10 residents observed for infection prevention and control.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedure for ensuring residents are cared for with dignity by not communicating to residents while providing care and not replacing a resident's mattress that was visibly soiled and smelling of urine. This failure applied to two of five residents (R7 and R11) reviewed for dignity.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for hydration by not ensuring fluid intake was consistently monitored for a resident with Stage Five Chronic Kidney Disease. This failure applies to one of three residents (R8) reviewed for hydration.

Inspectors wroteBased on interview and record review, the facility failed to properly document a change in resident condition, including vital signs taken and administration of PRN (as needed) blood pressure medication in the resident's medical record. This failure affected one resident (R2) of three residents reviewed for change in condition.

Inspectors wroteBased on interview and record review, the facility failed to properly assess a resident's change in condition after showing signs of respiratory distress, changes in oxygen saturation, and a low blood pressure. This affected one of three (R1) residents reviewed for quality of care and assessments. This failure resulted in R1 suffering a delay in being sent to the hospital, having a critically low blood pressure, and being tachycardic upon the paramedics' arrival. Findings Include: R1 is a [AGE] year old with the following diagnosis: hemiplegia affecting the right side following a cerebral infarction, type 2 diabetes, chronic respiratory failure with tracheostomy status, gastrostomy status, and dysphagia. A Nursing note dated 2/11/24 at 8:39AM documents upon arriving for the morning shift, R1 was very lethargic and weak. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policies and procedures for preparing food under sanitary conditions by not wearing hair restraints properly, not performing hand washing when required, and not storing food in clean containers. This failure has the potential to affect all 141 residents currently receiving food items from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment was clean and free of pervasive odor of urine and failed to provide adequate housekeeping services. This failure affected six of six residents (R8, R17, R22, R37, R94 and R117) reviewed for environment and has the potential to affect all 47 residents currently in the 300 sections of the long-term care unit.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for adequate staffing by not ensuring there are enough staff to meet the resident's needs. This failure applies to five (R136, R146, R213, R214, R215) of 40 residents reviewed for staffing and has the potential to affect all 141 residents currently in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for infection control by not wearing PPE (Personal Protective Equipment) in isolation rooms as required, by not properly cleaning, storing, and dating respiratory care equipment, and by not practicing hand hygiene while preparing residents meal trays. This failure applied to nine (R22, R94, R102, R212, R213, R214, R219, R220, R221) of 40 residents reviewed for infection control and has the potential to affect all 141 residents currently in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide feeding assistance to a resident in a timely manner, which resulted in the resident attempting to feed themselves and spilling their lunch tray all over themselves and the bed. This failure applied to one of one (R362) resident reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to provide a low air loss mattress upon admission for a resident with two community acquired pressure ulcers: unstageable to the sacrum and a deep tissue injury (DTI) to the left heel. This failure applied to one of one (R125) resident reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provide proper and timely incontinence care for dependent residents and failed to ensure staff follow facility incontinence care guideline and facility's Certified Nurse's Aide (CNA) job description while providing care to residents. This failure affected two (R462 and R37) of six residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to achieve a medication error rate below 5%. Medication error rate was 27.59% and affected one (R32) of four residents reviewed during medication administration task.

Inspectors wroteBased on observations, interviews, and record review the facility failed to implement the plan of care with interventions to reduce and/or prevent the risk of falling to include placing non-skid socks or shoes on one resident This failure affected one (R5) of three residents reviewed.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to inform a physician of the onset of a resident's change of condition (R227), failed to monitor a resident's vitals as ordered (R227), failed to monitor blood sugars levels for residents with diabetes (R220 and R227). This failure affected 2 of 52 sampled residents. As a result, R227 was unable to be aroused by staff for over 5 hours (6:38AM-12:26PM) and experienced decreased oxygen levels before nursing/medical interventions were given.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent and treat pressure ulcer/pressure injury (PU/PI) development for residents who were at increased risk for PU/PI development, failed to provide ongoing skin assessments for the residents, failed to provide proper treatment to prevent worsening of pressure ulcers or infection and provide appropriate pain management. These failures affected four of four residents (R39, R228, R269 and R377) identified with issues concerning pressure ulcer or injury. As a result, R269 and R377 were admitted without pressure ulcers and developed infected pressure ulcers while at the facility. In addition, R377 death was linked to sacral osteomyelitis.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to prevent further decline of a contracture on bilateral hands for one (R78) of one resident reviewed for restorative program. This deficiency resulted in R78's range of motion on left wrist deteriorated from normal to moderate loss/50% of norm and on the right hand from normal to mild loss/75% of norm.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to ensure the call light was answered in a timely manner for 9 of 147 residents (R2, R18, R75, R77, R85, R97, R371, R379, R380) in the facility. Findings Include: On 10/31/22 at 11:00am, R371 was interviewed and said it takes the staff a very long time to respond to his call light. On 10/31/22 at 11:32 AM, R379 was interviewed and said it sometimes takes 20-25 minutes for staff to respond to call lights because they are short staffed. On 10/31/22 at 1:42 PM, R380 stated he has had to wait for someone to respond to his call light for 2-2.5 hours. One time he had to wait this long with poop in his pants to be changed. R380 stated he must wait long periods of time because they're understaffed. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to label insulin pens with the date open and the expiration day, failed to refrigerate insulin and/or injectable medications upon the receipt from the pharmacy, failed to accurately reconcile controlled substance, failed to keep external medications in a treatment cart or in a separate drawer, failed to removal outdated medication from refrigerated medication storage and failed to prevent the maintenance of unlabeled/unknown medication in a cup within the medication cart; which prohibited the facilitation of safe precautions and safe administration of these drug and biological medications. This applies to 10 of 32 residents (R20, R39, R108, R113, R121, R122, R123, R124, R125, R220) residents reviewed for medication storage and labeling during the inspection the of the first and second floor medication room & cart.

Inspectors wroteBased on observation, interview and record review the facility failed to properly prevent and treat infestation of flying gnats and cockroaches in resident care areas. This failure affects all the residents living in the facility. During the survey, small flying insects were observed by all surveyors in resident care areas. On 11/03/22 at 4:45PM V18 Maintenance Director said, the exterminator comes twice monthly and as needed. We still have an ongoing issue with flies, beetles, and roaches on both the Long Term Care side and the Rehabilitation unit. Because we are still undergoing construction, it disrupts the walls where bugs would be living and allows them to come in from the outside. There have been sightings in both sides of the building. Pest Control log reviewed 5/4/22 which indicated activity of roaches in resident rooms 301-325. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to follow its policy related to changing of bed linens when wet or soiled for six of seven residents (R15, R43, R82, R111, R119 and R169) identified with issues for clean and comfortable home-like environment.

Inspectors wroteBased on interview and record review, the facility failed to screen residents and failed to provide documentation of level 1 PASAR screening for residents. This failure affected four residents (R1, R59, R66 and R78) of seven residents reviewed for PASRR screening. Findings Include: R1 is a [AGE] year-old male who was admitted to the facility on [DATE]. Review of medical record did not show any documentation of a PASRR screening for the resident. Facility presented a document with a screening date of 11/02/2022. R59 is a [AGE] year-old male who was admitted to the facility on [DATE]. Review of medical record did not show any documentation of a PASRR screening for the resident. R66 is a [AGE] year-old female admitted to the facility on [DATE]. Review of medical record did not show any documentation of a PASRR screening for the resident. [...]