Arcadia Care Aledo

Based on observation, interview, and record review the facility failed to ensure multi-dose injectable insulin pens were labeled with the date when opened for three of 12 residents (R22, R29, and R35) reviewed for storage and labeling of medications in a sample of 25.Findings include:The facility's Medication Storage Policy dated 12/25 documents, Purpose: To ensure proper storage, labeling, and expiration dates of medication, biologicals, syringes, and needles. Facility staff should record the date opened on the medication container when the medication has shortened expiration dates once opened.On 5/11/26 at 9:30 AM V9 (LPN/Licensed Practical Nurse) was standing at the North and Short Hallway medication cart. V9 opened the top drawer of the medication cart where residents' multi-dose insulin injector pens were stored. This drawer contained R22's opened 1/3 full Lantus Insulin100 u/ml (units/milliliter) injector pen that was not labeled with the date when opened, R29's opened 1/4 full Lantus Insulin 100 u/ml injector pen that was not labeled with the date when opened, and R35's…

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

Based on observation, interview, and record review failed to conduct regular maintenance inspections as part of a regular maintenance program to identify areas of possible entrapment for three of three residents (R21,R35, and R40) reviewed for side rail use in a sample of 25.The facility's Side Rails/Bed Rails Policy dated 12/25 documents, Purpose: To ensure the appropriate, safe, and correct installation, use, and maintenance of bed rails. Definitions: Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sized ranging from full to one-half, one-quarter, or one-eight lengths. Guidelines: The facility should ensure the bed is appropriate for the resident and that bed rails are properly installed and maintained. Potential risks can be exacerbated by improper match of the bed rail to bed frame, improper installation and maintenance, and use with other devices or supports that remain when the bed rail is removed. Installation and Maintenance of Bed Rails: Assuring the correct installation and maintenance of…

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

Based on interview and record review the facility failed to ensure residents were free from verbal abuse for 4 of 4 residents (R1-R4) reviewed for verbal abuse in the sample of 7.The findings include:The facilities Final Report dated 4/8/26 showed, at approximately 5:50 PM on 4/3/26 the administrator was notified of an allegation of verbal abuse between R1, and 3 other residents (R2-R4) in the dining room. Staff interviews: housekeeping: R1 entered dining room and made unclear statement as she walked by the 3 residents. Other residents started yelling back. All yelled curse words at each other. Nurse: heard residents yelling profanities at each other. Residents separated, R1 put on 1:1 supervision due to threatening behavior.Residents were interviewed on 4/3/26 and written statements were obtained by the facility. R5's statement showed R1 came into the dining room and started chewing everyone's butts. He believed R1 started it. R6's statement showed R1 was walking around the table behind R3 and R4. Something was said and everyone started yelling and screaming at each other. R1 got…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was assessed for injury after a fall and prior to being transferred for 1 of 3 residents (R1) reviewed for post-fall assessments in the sample of 3.The findings include:R1s admission record documents she was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 12/12/25 incident report for R1 shows she was ambulating in hallway and was behind double doors, door bumped into R1 causing change of plane. Under injuries it was indicated R1 had discomfort to right side.On 2/7/26 at 2:33 PM, V13 Dietary cook said she was taking the lunch cart into the unit. She put the code in and did not see R1 behind the door. She said R1 was right by the crack of the door and the wall and did not see her before pushing open the door. When she entered the unit, R1 fell. V13 said after R1 fell, she went to get V11…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff refused to provide toileting assistance to two of two residents (R6 and R7), reviewed for Activities of Daily Living assistance, in a sample of 8. R6's Assessment Progress Note, dated 9/19/25 documents, 9/19/25 admitted from local hospital with diagnoses of Major Depressive Disorder and Acute Pain. R6's Nursing admission Assessment, dated 9/19/25, documents R6 as, Alert, oriented to person, place, time. Toileting assistance as requiring substantial/maximal assistance.R6's (facility) handwritten statement, dated 9/23/2025 documents, Friday I was admitted in to (facility). I had fallen asleep and when I woke up it was 6:12 P.M., I hit my call light, (I) was in need of using (the) bed pan. At 6:55 P.M., Head Nurse (V6/RN) came in and advised me that they had 5 residents that require(d) feeding assistance and once they are done, she has to over watch the dining area while 5 assisted (residents) are taken care of. Then she stopped and asked if I had gotten my food…

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

Based on record review and interview the facility failed to assess one resident (R1) of three reviewed for fall risk.R1 was admitted to the facility 12/28/23 with diagnoses to include, but not limited to: Major Depressive Disorder, Benign Prostatic Hyperplasia, Hypertension, Diabetes, and Cerebral Ischemia.R1 fell 10/28/25 at 5:05 AM resulting in R1 sustaining a right hip fracture.The facility's Fall Prevention Program policy dated 05/2025 documents, The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident.R1's medical record does not document a fall risk assessment completed November 2024 through August 2025.On 11/7/25 at 1:28 PM, V1 (Director of Nursing) verified R1 did not have a fall risk assessment completed quarterly November 2024 through August 2025.On 11/12/25 at 12:32 PM V11…

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

Based on interviews and record review, the facility failed to protect 3 residents (R2, R4, R6) from physical abuse by another resident, and failed to protect a resident from abuse by a staff member for 1 resident (R7). These failures apply to 4 of 7 residents reviewed for abuse in the sample of 7.The findings include: 1. Preliminary Abuse Investigation Report with incident date of 08/04/2025 documented at approximately 04:40 PM, shows R2 was allegedly involved in a physical altercation with a peer (R1). R2's interview form documented R2 was unable to recall any details related to incident. No final report was provided. R1's electronic face sheet printed on 08/23/2025 documented an admission date of 05/12/2025 with a past medical history not limited to dementia with behavioral disturbance, anxiety disorder, major depressive disorder, mood affective disorder, and hypertension. R1's Minimum Data Set (MDS) Section C for Cognitive Patterns provided on 08/23/2025 indicated that R1 has severe cognitive impairment, dated 07/15/2025.R1's care plan detail reads in part: is/has potential to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. The facility face sheet shows R5 was admitted to the facility with diagnoses to include cerebral infarction, hypertension and alcohol dependence. R5's facility assessment dated [DATE] shows him to be cognitively intact with no behaviors and requires standby assistance from staff for mobility. A nursing progress note dated 6/24/2025 shows R5 was in an incident with another resident. On 7/2/2025 at 12:30 PM, R5 said he was walking to his room from lunch and R6 came up to him and accused him of stealing his shirt and underwear. R5 said R6 hit him on his arm and continued yelling at him. R5 said a staff member came up to the situation right away and he was not physically harmed by R6. On 7/2/2025 at 1:24 PM, R6 said he does not remember the incident. On 7/2/2025 at 12:55 PM, V5 Certified Nursing Assistant (CNA) said she was helping another resident to the toilet when she heard yelling in the halls. V5 said she ran to the yelling and saw R6 hit R5 in the arm and R6 was yelling at R5 saying he had stolen his shirts…

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

Based on observation, interview, and record review, the facility failed to ensure the tops of stationary kitchen equipment, next to food preparation areas, are free of dirt/debris. This failure has the potential to effect all 38 residents residing in the facility. FINDINGS INCLUDE: Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 3/12/2025, signed by V1/Administrator, document 38 residents reside in the facility. On 3/11/2025, at 10:25 a.m., during the initial kitchen tour, with V4/Dietary Manager, the tops of the upright refrigerator and upright freezer were covered with dirt and debris. These two pieces, of equipment, are sitting next to the food preparation tables. On 3/11/2025, at 10:25 a.m., V4 confirmed, due to ventilation/air movement, the tops of stationary equipment should have been cleaned.

Based on observation, interview, and record review, the facility failed to ensure the lids of trash dumpsters, located outside, are closed/secure to prohibit pests/animals from gaining access to discarded food/trash. This failure has the potential to effect all 38 residents residing in the facility. FINDINGS INCLUDE: Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 3/12/2025, signed by V1/Administrator, document 38 residents reside in the facility. On 3/11/2025, at 10:25 a.m., during the initial kitchen tour, with V4/Dietary Manager, the lids of the trash dumpster, located outside, were left open. The large, steel, trash dumpster, is not secured by any walls/access doors. On 3/11/2025, at 10:25 a.m., V4 confirmed, the trash dumpster lids should be kept closed in order to prohibit access by pests/animals.

Based on record review and interview the facility failed to use a set standard to determine the presence of an infection. This failure has the potential to affect all 38 residents who currently reside in the facility. Findings Include: The Facility's Antibiotic/Antimicrobial Stewardship Program policy dated 10/24 documents This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the unnecessary use of antibiotics. This program helps ensure that our residents get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium Difficile Infections, and reduce healthcare costs. The Facility's Antibiotic/Antimicrobial Stewardship Program policy documents The Medical Director will set standards for antibiotic prescribing practices for all physicians providing care in the facility , review antibiotic use data gathered by tracking and monitoring, and providing feedback and recommendation to ensure that best…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an appropriate indication for use for four residents (R2, R15, R29, R39) receiving psychotropic medications, failed to identify behaviors requiring the use of psychotropic medications and failed to attempt a Gradual Dose Reduction for (R2) of five residents reviewed for unnecessary medications in the sample of 28. Findings include: Facility Policy/Behavioral Health Services Program dated 2025 documents: Review behaviors and interventions implemented during daily or weekly clinical review meetings. Review Care Area triggers for mood, behavior and/or psychotropic medications. The care plan should reflect: Baseline and ongoing details (e.g., frequency, intensity, and duration) of common behavioral expressions (targeted behavioral symptoms) and expected response to interventions. Identified or suspected triggers specific to each resident (environmental, emotional, physical, etc.) that may exacerbate behavioral symptoms. Specific…

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

Based on record review and interview the facility failed to assess a new resident before transfering resident appropriately for one resident (R27) of 8 residents reviewed for accidents in a total sample of 28. This failure caused R27 to have a near fall that resulted in a broken toe. Findings Include: R27's admission nurse's notes dated 1/10/25 at 2:10 PM document resident is currently a (mechanical lift) for all transfers. On 3/11/25 at 9:00 AM R27 stated they (staff) got me up on a commode with two people and I did fine on the way to the commode but on the way back to the bed my legs did not work, and I stumbled. They used 5 people to get back to the commode and then used a (mechanical lift) to get me back in bed. When I stumbled my right foot got dragged across the floor. It started hurting the next day and then it started to bruise so we got an x-ray. I had a broken toe and had to wear a boot for a while. R27's Nurse's note dated 1/13/25 at 1:155 PM documents this nurse (V8/Registered Nurse) was called to resident's room to assist with a near fall during stand pivot turn…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess and identify triggers for one resident (R6) with a Primary Diagnosis of PTSD (Post Traumatic Stress Disorder) of two residents reviewed for Mood and Behavior in the sample of 28. Findings include: Facility Policy/Behavioral Health Services Program dated 2025 documents: Mental Health Rehabilitated Services and behavior management program for Mental Illness and Intellectual Disabilities and other related disorders such as Substance Abuse Disorder and residents with a history of trauma and/or Post Traumatic Stress Disorder. The facility will attempt to identify, to the extent possible, any previous history of mental illness, trauma, abuse, substance use, comorbidities, pattern of behaviors, preferences, interests, daily routines, medication use and effective behavior management interventions in developing an individualized plan of care. The care plan should reflect: Identified or suspected triggers specific to each resident…

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

Based on observations, interview and record review the facility failed to prevent resident to resident physical abuse for one resident (R2) of three residents reviewed for abuse in the sample of three. Findings include: Facility Policy/Abuse Prevention and Reporting dated 9/2024 documents: This facility prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes, hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.…

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

Based on observation, interview and record review the facility failed to initiate interventions to prevent resident to resident abuse for one resident (R2) of three residents reviewed for abuse in the sample of three. Findings include: Facility Policy/Abuse Prevention and Reporting dated 9/2024 documents: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making necessary changes to prevent future occurrences. Protection of Residents: The facility will take steps to prevent potential abuse while investigation is underway. Residents who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to notify the doctor and obtain wound treatment orders for one resident (R1) and failed to investigate, monitor, and implement new fall interventions for two residents (R1, R2) of three residents reviewed for accidents and injuries in a total sample of three. Findings include: A facility policy titled Incident and Accidents - Illinois last revised 05/2022 documents, The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident-to resident altercations. A section titled Procedure defines an accident as, any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. An incident/accident report will be completed for all serious accidents or incidents of residents, all unusual occurrences and any…

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

Based on observation, record review and interview the facility failed to ensure nurse aides who provide direct patient care are not employed full time for more than four months without successfully completing a state approved training and competency evaluation program. This failure has the potential to affect 44 of 44 residents in the facility (R1-R44). Findings include: On 07/30/24 at 10:49AM, V4/Nurse Aide was observed working with residents on the secured unit in the facility. An active Employee roster dated 07/30/24 at 8:26am documents V4 is a CNA (Certified Nurse Aide) with a hire date of 02/02/22. V4's personnel file shows V4 is Eligible to work per the Illinois Department of Public Health - Health Care Worker Registry. V4's start date at the facility is 02/02/22 under the title of House Keeping - Cleaner. On 08/01/23 the facility changed V4's title on the Health Care Worker Registry to Technical, Unlicensed Health Care - Certified Nurse Aide. V4's Health Care Worker Registry page documents the following, Certification Program Information: No programs on Record, Date training…

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

Based on observation, interview and record review, the facility failed to assess, notify the physician and obtain a treatment order for a newly identified pressure wound for one of three residents (R2), reviewed for pressure wounds, in a sample of 3. The facility policy, Decubitus Care/Pressure Area, dated (revised) 1/18 documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. Upon notification of skin breakdown, the pressure area will be assessed and documented on the Treatment Administration record or the Wound Documentation Record. Document size, stage, site, depth, drainage, color, odor, and treatment (after obtaining from the physician). Notify the physician for treatment orders. The orders should include: type of treatment, frequency treatment is to be performed, how to cleanse, site of application. R2's (Hospital) After Visit Summary, dated 6/29/24 to 7/5/24 documents that R2 was readmitted to the facility with the following diagnoses: Closed Fracture of…

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

Based on interview and record review, the facility failed to obtain and administer physician- ordered medication for one of three residents (R1), reviewed for medications, in a sample of three. The facility policy, Medication Administration, dated (revised) 11/18/17 documents, Drug administration shall be defined as an act in which a single dose of prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. Document any medications not administered for any reason by circling initials and documenting on the back of the MAR (Medication Administration Record) the date, time, medication and dosage, reason for omission and initials. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Like medications are not to be borrowed from one resident for another. Notify the physician as soon as practical when a scheduled dose of medication has not been administered for any reason.: R1's (facility) Cumulative Diagnosis Log documents…

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

Based on observation, interview, and record review the facility failed to administer a physician prescribed antibiotic medication to a resident with a diagnosis of lower extremity cellulitis for one of three residents (R1) reviewed for infections in the sample of three. Findings include: The facilities Medication Administration Policy, dated 7/3/2013, documents The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. The same policy also documents Medications must be prepared and administered within one hour of the designated time or as ordered. Medications must be identified by using the six rights of administration: right resident, right drug, right dose, right time, right route, right documentation. On 6/17/2024 at 10:30 AM, R1 was sitting in her wheelchair at her bedside. R1's left lower leg was wrapped with a bandage and resting on her…

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

Based on interview and record review the facility failed to ensure physician ordered laboratory tests were collected as ordered for one of three residents (R1) reviewed for infections in the sample of three. Findings include: The facilities Laboratory Test Policy, dated 9/27/2017 documents Appropriate laboratory monitoring of disease process and medications requires consideration of many factors including concomitant disease and medications, wishes of the resident and family and current standards of practice. Responsibility; physician, license nursing personal, laboratory consultant, pharmacy consultant. Procedure: laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. R1's Physician Order Sheet, dated 5/1/2024-5/31/2024, documents on 5/29/2024 R1 had an order to Collect CBC (complete blood count), BMP (basic metabolic panel), ESR (Erythrocyte Sedimentation Rate), CRP (C-Reactive Protein test) on Tuesday 6/4/2024 and send to V9 (Infections disease physician) and follow up with V9 on 6/4/2024. R1's Laboratory…

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

Based on interview and observation, the facility failed to ensure resident's clothing was labeled in a dignified manner. This failure has the potential to affect all 44 residents to reside at the facility. Findings include: During a tour of the Laundry Department on 6/3/24 at 1:30 PM, V18 (Housekeeping Supervisor) stated the facility no longer provides labels to the residents to identify their clothing. V18 demonstrated a black marker and stated We (housekeeping/laundry staff) have to write the residents name on the inside of their clothing (with the black marker). It's hard because you can't always read it on dark clothing and if there is not a tag (manufacturer tag) we (housekeeping/laundry staff) can write on, there is no way to identify it (clothing). Some of the residents have nicer articles of clothing and it just ruins the piece. V18 demonstrated multiple residents' pieces of clothing which had been washed and hanging on hangers that had the residents name or residents initials written on the collar of shirts. On 6/4/24 at 1:15 PM during the Resident Council Meeting, R147…

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

Based on observation, record review and interview, the facility failed to ensure grievances or recommendations are considered, addressed and acted upon. This failure has the potential to affect all 44 residents who reside at the facility. Findings include: The Resident Grievances/Complaints policy, no date, documents 1. Resident Council meetings are to allow time for Residents to address complaints, grievances and other concerns which shall be reflected in minutes of the meeting. The facility liaison to the Resident Council shall direct complaints and grievances to the appropriate Department Head who will resolve the complaint and/or grievance. The Administrator shall also receive copies of the minutes so he/she can follow up to insure resolution. 6. Grievance and complaint investigations shall be completed within 15 days by the Investigator. 6. The Investigator shall notify the Resident and document the results of the investigation and notification on the grievance/complaint form. The Social Service Director is responsible to notify the family and resident representative of the…

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

Based on observation, interview and record review, the facility failed to post the daily direct care staff hours and resident census. This has the potential to affect all 44 resident's residing in the facility. On 6/2/24 at 9:15 AM a tour was conducted of (the facility). No daily nursing hour data and census sheet was observed throughout the entire building. On 6/2/24 at 12:00 PM V2 (DON/Director of Nursing) stated, I was not aware that I was supposed to be filling out a sheet that includes the census for the day and the total number of staff and actual hours worked per shift for RN's (Registered Nurses), LPN's (Licensed Practical Nurses), and CNA's (Certified Nursing Assistants). V2/DON verified she has not posted the daily nursing staff data since she started as DON in March 2024. V2 stated, I would post the daily census for the day and the total number of staff and actual hours worked in the glass case outside of V1's/Administrator's office. On 6/3/24 at 10:00 AM there was no daily nursing staff data posted in the glass case on the wall or anywhere else within the building. On…

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

Based on observation, interview and record review the facility failed to ensure equipment in the facility kitchen was clean and free of debris, failed to date cooked food items to ensure use before expiration, and failed to monitor and record the required refrigerator, freezer temperatures, food temperatures of served foods and the required dishwasher sanitation levels. These failures have the potential to affect all 44 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, Refrigerator and Freezer Storage, dated (revised) 10/14 directs staff, It is the policy of (facility) that any item to be placed in the refrigerators and freezers must be covered, labeled and dated with a date-marking system that tracks when to discard perishable food. The facility policy, Storage, dated (revised) 10/20 directs staff, Store leftovers in covered, labeled and dated containers under refrigeration or frozen. When using only part of a product, the remaining product shall be in the original package or air tight container and labeled and dated. The facility policy, Dish…

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

Facility failures resulted in two deficient practices. A. Based on record review, and observation, the facility failed to place signage in a conspicuous location to clearly identify the category of transmission-based precautions, instructions for PPE (Personal Protective Equipment) and/or instruction to see the nurse prior to entering the resident's room for 1 of 1 (R32) residents that required transmission-based precautions in a sample of 43 residents. B. Based on interview and record review the facility failed to have interventions in place to mitigate the growth and spread of legionella and failed to maintain logs of interventions. This has the potential to affect all 44 residents that reside at the facility. Findings include: A. The Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings, revised 11/30/09, documents 2. Multi-resistant drug organisms are bacteria and other microorganisms that have developed resistance to antimicrobial drugs. Common examples of these organisms include: MRSA- Methicillin/Oxacillin-resistant Staphylococcus aureus. The Transmission-Based…

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

Based on interview and record review the facility failed to: implement an antibiotic stewardship program that included assessing and monitoring residents for signs and symptoms of infections; ensure antibiotic usage was appropriate, and use of a nationally recognized surveillance criteria to define infections for 3 of 3 (R34, R57, R58) residents reviewed for the Antibiotic Stewardship Program in the sample of 43 residents. This failure has the potential to affect all 44 residents who reside at the facility. Findings include: The Infection Control Surveillance and Monitoring policy, dated 4/11/22, documents It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. Monitoring of the day-to-day operations include: a. Investigation and implementation of controls to prevent infections in the facility. b. Determine and direct the correct procedures necessary for the prevention of infections. c. Follows up on documentation of, and reporting of infection to physicians, through direct,…

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

Based on record review and interview, the facility failed to designate a qualified infection preventionist who is responsible for the facility's Infection Prevention and Control Plan. This failure has the potential to affect all 44 residents who reside at the facility. Findings include: The Infection Control Surveillance and Monitoring policy, dated 4/11/22, documents The facility shall employee, at a minimum, a part time Infection Control Preventionist. These duties maybe performed by the Director of Nursing with an approved Infection Control Certification. The Infection Preventionist Job Description, dated 3/3/23, documents Qualifications: 2. Must have completed Specialty Training in Infection Prevention and Control through accredited continuing education. On 6/3/24 at 11:00 AM, V2 (Director of Nursing/Infection Preventionist) stated V2 was the designated Infection Preventionist although no specialty training in Infection Prevention and Control had been completed at this time. On 6/5/24 at 2:00 PM, V1 (Administrator) stated V2 was hired on 3/19/24 and has not had the time to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to offer immunizations and vaccinations in 5 of 5 residents (R12, R14, R39, R40, R96) per policy. This failure has the potential to affect all 44 residents who reside at the facility. Findings include: The Immunization of Residents policy, dated 5/19/23, documents Verify the date of last vaccination. Obtain proof of previous Pneumococcal and Influenza vaccination for residents when able. Assess all newly admitted resident's pneumococcal and Influenza vaccination status upon admission and record last known immunization on the resident's Immunization Record. Offer the (Pneumonia Vaccination) unless contraindicated. Offer the Influenza annually from September 1st thru March 31st. Offer the current recommended COVID-19 Vaccine upon admission for those identified as not being up to date with recommended vaccination. Document immunization on the resident's Medication Administration Record and on the Resident's Immunization Record. R12 was admitted on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to ensure the resident's memory care unit had warm water and was clean and free of odors for 19 of 42 residents (R2, R3, R4, R7, R8, R10, R11, R16, R20, R21, R22, R25, R27, R31, R33, R41, R42, R43, and R247) reviewed for safe clean and homelike environment in the sample of 43. Findings include: The facility's Water Temperature monitor Policy-Resident Areas policy (undated) states, Policy: Ensure warm water temperatures are within the range of 100 degrees to 110 degrees for Resident areas and warm water is deliver to each faucet in timely manner. Water temps are to be taken at least once a week to ensure temperatures are within proper parameters. Any adjustments necessary will be immediately made to ensure comfortable and safe water temps. The facility's Housekeeper policy (undated) stated, Job Summary: Housekeepers are responsible for maintaining the facility in a clean, orderly, and sanitary manner. Responsibilities: 1. Duties a) Clean,…

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

Based on observation, interview and record review, the facility failed to ensure medications were kept stored in their original packaging with labels until administered for four of forty-three residents reviewed (R7, R20, R27, and R43) for medication administration, storage, and labeling in the sample of 43. The facility policy, Medication Administration dated (revised 7/3/13) directs staff, Medications must be prepared and administered as ordered (by the physician). All medications must be labeled with the resident's name, the medication, the dosage and instructions for administration. On 6/2/24 at 8:25 AM V17 (Agency Licensed Practical Nurse) was standing at her medication cart next to the dining room on the Dementia locked unit. V17 opened the top left drawer of her medication cart where there were four medication cups labeled with a first name all full of medications. V17 stated, I pre-popped (R7), (R20), (R27), and (R43's) 8:00 AM medications. I did not administer the medications immediately and only labeled the medication cups with their first name. I know I am not supposed to…

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

Based on interview and record review the facility failed to notify the facility Ombudsman monthly of a resident transfer to the hospital and failed to provide the resident and resident representative with a written notice of transfer, for one of two residents (R26) reviewed for hospitalizations, in a sample of 43. Findings Include: R26's medical record documents that R26 was transferred to a local hospital on 2/12/24. No evidence of a facility notification to R26 of a transfer/discharge was present on R26's chart. On 6/4/24 at 1:30 P.M., V18/Social Services Director verified that the facility did not provide R26 or his representative with a written notice of transfer. At that time, V18/Social Services Director also confirmed that she had not sent notification to the local Ombudsman of monthly facility transfers/discharges.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for one of two residents (R26), reviewed for bed holds, in the same of 43. Findings Include: R26's medical record documents that R26 was hospitalized on [DATE]. R26's medical record does not contain documentation of written notice to R26 or R26's resident representative, of the facility bed hold policy. On 6/4/24 at 1:30 P.M., V18/Social Services Director verified that the facility did not provide R26 or his representative with a a Bed Hold Policy or a written Notice of Transfer.

Based on interview and record review the facility failed to monitor a physician's order for self-catheterization and failed to update a resident's care plan to reflect self catherization needs for one of two residents (R18) reviewed for catheters, in a sample of 43. FINDINGS INCLUDE: The facility policy, Comprehensive Care Planning, dated (revised) 7/20/22 directs staff, It is the (facility) policy to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care .The care plan shall be reviewed and revised as necessary to reflect the resident's current medical, nursing and mental and psychological needs as identified. R18's Cumulative Diagnosis Log documents R18's diagnoses as Hereditary Spastic Paraplegia, Neurogenic Bladder. R18's Physician Order, dated 11/20/2023 and signed by V13/Physician/Medical Director documents, Resident may continue self-…

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

F698 Based on observation, interview and record review the facility failed to obtain a physician's order for dialysis treatments, update a plan of care, for a resident receiving dialysis services and failed to assess a resident's dialysis fistula for hemorrhage post-dialysis for one of one residents (R26) reviewed for dialysis, in a sample of 43. FINDINGS INCLUDE: The facility policy, Comprehensive Care Planning, dated (revised) 7/20/22 directs staff, It is the (facility) policy to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care .The care plan shall be reviewed and revised as necessary to reflect the resident's current medical, nursing and mental and psychological needs as identified. The facility policy, Dialysis, dated (revised) 01/02 directs staff, Dialysis is another name for artificial kidney treatment. It is a medical procedure,…

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

Based on record review and interview the facility failed to administer an IV (Intravenous) medication as ordered by the physician for one resident (R32) of 16 residents reviewed for medication administration, in a sample of 43. Findings Include: The facility policy, revised 7/3/2013, named Medication Administration, documents the following: Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. 22.) Notify the physician as soon as practical when a scheduled dose of a medication has not been administrated for any reason. R32's Cognitive Assessment, dated 2/7/2024, documents R32 has a BIMS (Brief Interviews for Mental Status) of 15. R32 is cognitively intact. R32's Wound culture results from the wound clinic dated 5/9/2024, documents, Culture results: Moderate growth of Methicillin Resistant Staphylococcus Aureus (MRSA) is isolated. vancomycin (antibiotic used to treat bacteria) is susceptible to the MRSA. R32's Progress…

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

Based on Interview and Record review the facility failed to prevent resident to resident sexual abuse for two of three residents (R1, R2) reviewed for Abuse in the sample of three. Findings include: The facility's Abuse Prevention Program policy, dated 11/28/16, documents The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptom. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents This policy also documents Sexual Abuse is non-consensual sexual contact of any type with a resident. The facility's…

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

Based on Interview and Record Review, the facility failed to revise a resident care plans to include an incident of resident to resident sexual abuse for two of three residents (R1, R2) reviewed for Abuse in the sample of three. Findings include: The facility's Comprehensive Care Plan (CCP) policy, dated 11/1/17, documents It is to be noted that the Care Plan is for planning care and services. Actual documentation of delivery of care is accomplished in the Nurse's Notes, administration records, flow records and other locations throughout the chart as appropriate. Where frequent changes occur in orders, the care plan may contain a general intervention that references where in the chart more specific interventions/orders can be located. The CCP shall be reviewed after each Annual, Significant Change and Quarterly MDS (Minimum Data Set assessment) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDT (Interdisciplinary Team). The Care Plan shall be revised as necessary when the needs/problems and care and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to notify the family of one resident (R1) of a condition change of three residents reviewed for falls. Findings Include: The facility's Notification for Change in Resident Condition or Status dated 7/1/2012 documents The facility and/or facility staff shall promptly notify appropriate individuals (i.e. Administrator, DON, Physician, Guardian, HCPOA, etc) of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the DON, physician, and unless otherwise instructed by the resident, the resident's next of kin or representative when the resident has any other afore mention situations. b. an accident or incident involving the residentg. Refusal of treatment or medications (i.e. three or more consecutive times. h. A need to transfer the resident to a hospital/treatment center. R1's Medical Record documents that R1 was admitted to the facility's Alzheimer's Unit on 10/5/2022 with diagnosis of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY These failures resulted in two deficient practices. A. Based on record review and interview the facility failed to monitor a resident after a fall and failed to initiate new interventions to prevent falls for two residents (R1 and R3) of three residents reviewed for falls with injury. B. Based on record review and interview the facility failed to assess one resident (R3) for the potential to harm himself after a suicidal statement of three residents reviewed for accidents and supervision. Findings Include: The Facility's Fall Prevention policy dated 08/2006 documents the policy is to provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. The Facility's Fall Prevention policy dated 08/2006 documets that the Charge Nurse will Complete a 72 hour fall intervention and place in the MAR (Medication Administration Record); place the resident on the 24 hour report with fall and new intervention to be…

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

Based on observation, interview, and record review the facility failed to ensure an accurate shift-to-shift controlled medication inventory count, failed to ensure refrigerated controlled medications were immediately double locked, and failed to ensure controlled medication tracking sheets had accurate reconciliation. This failure has the potential to affect all 16 residents (R1 - R15) who have physician orders to receive controlled medications. Findings include: Facility Policy/Missing Controlled Substance dated 2010 documents: It is the policy of this facility to prevent the loss of controlled substances and vigorously investigate incorrect inventory of controlled drugs, medications or pharmaceuticals reported by pharmacists, physicians or licensed nurses. All controlled drugs will be counted by the oncoming and outgoing nurse at the change of each shift as per the Controlled Drug Policy and Procedure. The count of each controlled medication will be maintained on the drug disposition sheet for each individual medication as per the Controlled Substance Policy. The oncoming and…

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

Based on observation, interview, and record review the facility failed to prevent misappropriation of narcotic medication for one resident (R1) of three residents reviewed for controlled medications. Findings include: Facility Policy/Abuse Prevention Program dated 11/28/2016 documents: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. Misappropriation of Property is the deliberate misplacement, exploitation, or wrongful temporary or permanent use of residents' belongings or money without resident consent. Missing Controlled Substance-Investigation Worksheet indicates on 4/25/24 at 6:00am one dose of R1's Hydrocodone-Acetaminophen (narcotic) 5-325mg (milligram) was missing. On 5/8/24 at 1:45pm V9, DON (Director of Nursing) stated that V3, RN (Registered Nurse) went to the hospital (on 4/24/24) at 8:30pm and was found to have been impaired so V4, RN was called to come in early to replace V3. V9 stated the police arrived to the facility at approximately 1:30am after being notified…

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

Based on interview and record review the facility failed to check the nursing license status of a nurse prior to employment. This failure has the potential to affect all 48 residents who reside in the facility. Findings Include: The Facility's Nurse Staffing Policy dated 12/07/2017 documents No person may provide direct resident care without a certification and records check. The Facility's Administrator job description documents Personnel Functions: Ensure that appropriate identification documents are present prior to the employment of personnel and that and that appropriate documentation is filed in the employee's record in accordance with state and federal regulations. The Facility's Nursing Schedule for February and March 2024 documents V5 (Licensed Practical Nurse) worked the following days: 02/10/24,02/11/24,02/13/24,02/14/24,02/15/24,02/19/24,02/20/24,02/22/24,02/25/24,02/27/24,02/29/24,03/04/24,03/05/24,03/07/24,03/09/24,03/10/24,03/12/24. The Illinois Department of Professional and Financial Regulation website shows that V5's LPN license was suspended effective 02/05/24 for…

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

Based on interview and record review the facility failed to have a licensed Administrator and failed to thoroughly investigate an incident of finding used needles and syringes. This failure has the potential to affect all 48 residents who currently reside in the facility. Findings Include: The Facility's undated Administrator job description documents Job Summary: The Administrator is responsible for directing the day to day functions of the facility in accordance with current local, state and federal standards and guidelines and regulations that govern long term care facilities to assure that appropriate care is provided in the facility. The Administrator is responsible for delegating the Administrative authority, responsibility necessary for carrying out duties. The Facility's Administrator job description also includes qualifications: Must possess a current unencumbered Nursing Home Administrator's License or meet the license requirements of this state. 1. On 3/24/24 at 9:30 AM V1 (Administrator in Training) stated she had been an Administrator in Training for about three or four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to update a plan of care for one resident (R7) of three residents reviewed for wounds, in a sample of 13. FINDINGS INCLUDE: The facility policy, Comprehensive Care Planning, dated (revised) 7/20/22 directs staff, It is the (facility) policy to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care .The care plan shall be reviewed and revised as necessary to reflect the resident's current medical, nursing and mental and psychological needs as identified. R7's hospital Transfer Sheet documents that R7 was hospitalized from [DATE] to 2/7/24 for Cellulitis and Wound Debridement of Ulcers to the Left Lower Leg. This same form documents new wound treatments, new medication orders for treating Cellulitis and multiple new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physician ordered therapy services were provided to residents for three of four residents (R2, R6, and R7) reviewed for therapy services in the sample of 13. Findings include: The facility's Amended and Restated Therapy Services Agreement effective 10/1/2019 documents physical therapy/PT, occupational therapy/OT, and speech and language therapy will be provided in accordance with residents' applicable plan of care. The Facility Assessment Tool updated 2/13/24 documents the facility provides various services for residents including PT, OT, and Speech/Language Therapy. The facility's Protocol for the Facility Regarding Transportation Requests for Outside Vendor Appointments revised 11/15/23 documents the transportation driver will assist residents in arranging transportation to appointments and outside excursions. If other arrangements can't be made, the facility will provide transportation as the schedule allows. On 2/27/24 at 12:30…

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

Based on record review and interview the facility failed to provide adequate heat in the dining room. This failure has the potential to affect 13 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, and R13 that eat in the dining room. Findings Include: The facility policy named, Disaster Plan/Policies and Procedures, dated 9/25/2012, documents the following: It is the policy of this facility to provide continuing safe, and comfortable care to its residents in the event the facility heating, and furnace systems fail during periods of unseasonably cold outside temperatures are present and such systems are required for resident safety and comfort. According to the weather graph on Google the temperature outside on 2/17/2024 at 9:52AM was 35 degrees. The facility Resident Council Agenda, dated 12/4/2023, documents the following: No heat in rooms. The facility Resident Council Agenda, dated 1/8/2024, documents the following: No heat in the dining room. The facility Grievance Log, dated 2/5/2024, documents the following: No heat in dining room. On 2/17/2024 it was determined…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop comprehensive care plans for four residents (R3, R4, R5, R8) of eight residents reviewed for care plans in a sample of eight. Findings include: Facility Policy/Comprehensive Care Planning dated 11/1/17 documents: It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as a basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI (Resident Assessment Instrument) shall be the guide utilized for all comprehensive assessments, care area assessments and care planning. The Comprehensive Care Plan (CCP) shall be developed within 7 days of the completion of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to convey resident funds within 30 days of discharge for one resident (R1) of three residents reviewed for discharge in a sample of eight. Findings include: Profile Face Sheet indicates R1 was admitted to the facility on [DATE] and received Public Aid at that time. Social Service Progress Notes dated 10/25/23 indicate R1 was discharged to Assisted Living facility and that All belongings and medications sent. Social Service Progress Notes dated 11/20/23 indicates a phone call was received from R1's current facility asking about R1's money and discussed that (facility R1 was discharged from) was still (R1's) Representative Payee and current facility would need to contact the Social Security office to have R1's money routed to them if they preferred that. Social Service Progress Notes dated 12/5/23 indicate Received another call from (R1's) current facility. Discussed that he had been released from (State screening and assessment program) and discussed Social…

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

Based on interview and record review the facility failed to administer a physician ordered antidepressant medication for one resident (R5) and failed to administer two physician ordered antibiotics for one resident (R2) of three residents reviewed for medications in a sample of eight. Findings include: Facility Policy/Medication Administration dated 11/18/17 documents: Document any medication not administered for any reason by circling initials and documenting on the back of the MAR (Medication Administration Record) the date, the time, the medication and dosage, reason for omission and initials. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Notify the physician as soon as practicable when a scheduled dose of a medication has not been administered. On 1/5/23 at 10:45am R5 stated he felt as though his depression was worsening in the past few weeks and blew up at (V1, Administrator) over transportation issues. R5 stated when he blew up at V1, he was not aware he had not been receiving his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect residents (R4, R5) from physical abuse for two of four abuse allegations reviewed. Findings include: The facility's Abuse Prevention Program, dated 11/28/16, documents, This facility is committed to protecting our residents from abuse by anyone including; but no limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The program also documents, As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approached, which would reduce the chances of mistreatment, neglect, and abuse of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise a care plan following a resident to resident altercation for three of four residents (R1, R2, R4) viewed for care plans in the sample of six. Findings include: The facility's Abuse Prevention Program, dated 11/28/16, documents, As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approached, which would reduce the chances of mistreatment, neglect, and abuse of these residents. 1. The facility's Final Report to the State Agency, dated 8/1/23, documents, R2 has a history of wandering into other rooms. V1 (Administrator in Training) was notified by V3 (Care plan coordinator) that R1 shoved R2 causing R2 to land on her left hip and left arm. R2 was complaining of left hip pain. R2 was sent to the emergency room for evaluation and treatment.…

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