The Haven Of Arcola

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess/measure a pressure sore, administer a wound treatment according to physician's orders and accurately document the location of a pressure sore for one resident (R12) of two residents reviewed for pressure sores in a sample list of 33. Findings Include: R12's Care Plan updated 6/16/25 lists the following diagnoses: Hypomagnesemia, Chronic Pulmonary Edema, Quadriplegia, C5-C7 Complete, Neuromuscular Dysfunction of Bladder, Seizures, Cauda Equina Syndrome, Zoster Encephalitis, and Primary insomnia. R12's MDS Minimum Data Set, dated [DATE] documents R12 is cognitively intact. R12's admission Skin assessment dated [DATE] documents a Superficial wound (to the) Right Gluteal Fold measuring 0.2cm (centimeters) in Length by 0.2cm in width by 0cm in depth. R12's Physician's Order sheet documents a physician's order started on 4/24/25 and discontinued on 5/15/25 R (right) upper thigh. Cleanse with normal saline. Apply Mepilex every day shift…

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 have physician's orders for the use and care of Continuous Positive Airway Pressure (CPAP) for one of one resident (R25) reviewed for CPAP use in the sample list of 33. The facility's CPAP/BiPAP (Bilevel Positive Airway Pressure) Support policy dated April 2007 documents to review the physician's order to determine the oxygen flow rate and positive end-expiratory pressure settings. This policy includes to document a general assessment prior to the procedure, time/duration of therapy, CPAP settings, oxygen flow rate, oxygen saturation, and how the resident tolerated the procedure. On 9/07/2025 at 9:27 AM There was a CPAP machine on the overbed table next to R25's bed. The CPAP mask and tubing was in a plastic bag attached to the machine. R25 stated R25 has been in the facility for a few weeks and uses the CPAP at night. R25 stated the staff do not do any care for the CPAP. R25's active census documents R25 admitted to the facility 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 interview and record review the facility failed to ensure physician visits are documented for one of three (R40) residents reviewed for hospitalization in the sample list of 33. The facility's undated Physician Services Policy documents It is the policy of this facility that each resident admitted to this facility is under the care of a physician licensed in the State and that all physician services will comply with State and Federal regulations for resident care in a licensed facility. The attending physician shall write a progress note at the time of each resident visit and review the resident's total program of care; i.e. (in other words) comprehensive assessments, care plans, medication and treatments, and approving such by signing and dating the current order recap.R40's active census documents R40 has resided in the facility since 2004 and V21 Physician/Medical Director is R40's primary physician. This census documents R40 was hospitalized six times within the last year. R40's electronic medical record does not contain any physician visit notes by V21 within the last…

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 timely physician visits for one of three residents (R40) reviewed for hospitalizations in the sample list of 33. The facility's undated Physician Services Policy documents It is the policy of this facility that each resident admitted to this facility is under the care of a physician licensed in the State and that all physician services will comply with State and Federal regulations for resident care in a licensed facility. The attending physician shall write a progress note at the time of each resident visit and review the resident's total program of care; i.e. (in other words) comprehensive assessments, care plans, medication and treatments, and approving such by signing and dating the current order recap. The attending physician shall certify upon admission and at each visit every 30/60 days thereafter what level of care the resident requires, and document the (reason) for a change in the progress notes.R40's active census documents R40 has resided in the facility since 2004 and V21 Physician/Medical Director is…

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 log infections, organisms, and antibiotics and ensure the appropriate antibiotics were administered for one (R40) of five residents reviewed for infection control on a sample list of 33. Findings include:The facility's Antibiotic Stewardship Program Guidelines dated 4/29/2024 document that the purpose of the antimicrobial stewardship program is to improve antimicrobial stewardship practices and to monitor outcomes and antimicrobial use. This policy documents that the objective is that the Antimicrobial Stewardship Program will be to improve patient outcomes through optimization of antimicrobial therapy by selection of appropriate antibiotic dose, route, and duration of treatment, minimize the development of antimicrobial resistance by appropriately selecting antibiotics, and reduce the rates of facility-acquired infection. Guidelines document that the facility will monitor antibiotic use and outcomes from antibiotic use. The facility's Infection 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 interview and record review the facility failed to protect resident's right to privacy. This failure affected two of four residents (R1, R2) reviewed for resident rights on the sample list of four. Findings Include:The facility's Resident Rights Guideline policy dated October 2023 documents the practice of this facility is to provide an environment in which residents may exercise their rights, each day. Residents have certain rights and protections under Federal law and the facility will always protect these rights through care and related services. One example of a resident's rights is Privacy and Confidentiality. R1's Medical Diagnoses List dated August 2025 documents R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Behavior Tracking for July 2025 through August 2025 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements, invading the personal…

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 resident's right to be free from verbal abuse. This failure affected two of four residents (R1, R3) reviewed for resident rights on the sample list of four. Findings Include:The facility's undated Abuse policy documents Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident. R1's Medical Diagnoses List dated August 2025 documents R1 is diagnosed with Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. R1's Behavior Tracking for July 2025 through August 2025 documents R1 exhibits behaviors of attention seeking, repetitive questions/statements,…

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 resident dignity for three of three residents (R4, R5, R6) reviewed for dignity in a sample list of seven residents.R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. This same MDS documents R4 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene and bed mobility. R4's Care plan documents medical diagnoses as Thoracic Scoliosis, Depression, Neuropathy, Thrombophlebitis of Lower Extremities, Unsteady on Feet, Muscle Wasting and Atrophy and Major Depressive disorder. This same care plan initiated 11/8/24 does not document a focus area, goal nor interventions for R4's behaviors of consensual sexual behavior with male peers prior to 7/29/25. This same care plan documents R4 requires a wheelchair for mobility. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. R4 and R5's shared…

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 the resident's right to be free from verbal abuse by another resident. This failure affects two of four residents ( R2 and R7) reviewed for abuse in a sample list of eight residents. Findings include: The facility undated policy titled Abuse Prevention Policy documents abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a…

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 report allegations of verbal abuse to the Abuse Coordinator for three of four residents (R1, R2, R7) reviewed for abuse in a sample list of eight residents. Findings include: The facility undated policy titled Abuse Prevention Policy documents Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. 1. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. The facility was unable to provide documentation a resident (R2) to resident (R1) verbal altercation on 12/23/24 was reported 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 provide the services of a Registered Nurse for eight consecutive hours per day seven days per week. This failure has the potential to affect all 69 residents residing in the facility. Findings include: The facility's Nurses Schedule for October and November 2024 documents on 11/2/24, 11/5/24, and 10/29/24, there was not a registered nurse scheduled to work. The October Nurses Schedule documents on 10/27/24 there was a registered nurse working for four hours. On 11/8/24 at 9:15 AM, V1, Administrator, reviewed the Nurses Schedules and stated, I don't see an RN (Registered Nurse) on 11/3/(24), I don't see an RN on 11/5/(24), I don't see an RN on 10/29/(24). Correct on 10/27/(24) there was an RN for four hours. V1 further stated, We knew we would get this (citation), facilities are struggling with staffing. The facility's Form 802 Resident Matrix dated 11/6/24 documents 69 residents reside in the facility. The Department of Health and Human Services Center for Medicare and Medicaid Services Certification and Transmittal dated…

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 cross contamination during medication administration for four residents (R13, R56, R51, R270) out of six reviewed for medication administration in a sample list of 31 residents. Findings include: The facility policy titled Medication Administration revised 11/18/2017 documents appropriate hand washing is to be completed and/or alcohol based gel rub must be used throughout the medication pass. This should occur before and after medication pass and after touching an inanimate object possibly contaminated with microorganisms. Handwashing is not required per the Centers for Disease control (CDC) guidelines. It is acceptable to use alcohol based gel type solution between residents. The Facility Daily Midnight Census dated 11/6/2024 documents 69 residents reside in facility. On 11/7/24 at 7:22 AM V12 Licensed Practical Nurse (LPN) administered R56's medications. V12 LPN did not wash hands nor use an alcohol based hand rub (ABHR) prior to administering R56's medications. V12 LPN then proceeded to administer…

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 a new Level 2 PASRR (Preadmission Screening and Resident Review) to evaluate a resident's need for specialized mental health services upon the expiration of the initial Level 2 evaluation. This failure affects one resident (R28) out of 11 reviewed for pre-admission screening on the sample list of 31. Findings include: R28's Level 2 PASRR to evaluate for the need of specialized mental health services dated 8/17/2015 documents R28 had a history of inpatient mental health hospitalizations, experienced delusions, irritability, and difficulty remaining on tasks related to her medical diagnosis of Paranoid Schizophrenia. This Level 2 screening had a determination date of 8/24/2015 and documented R28 required specialized services including mental health rehabilitation services, illness self-management, and community re-integration activities. This Level 2 screening documented this determination was valid for 90 days from the date of determination (11/22/2015), and a new determination should be obtained from the entity…

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 complete a baseline careplan timely for one resident (R270) out of one reviewed for careplans in a sample list of 31 residents. Findings include: The facility policy titled Baseline Care Planning policy revised 3/16/22 documents the following procedure shall be utilized in developing a baseline careplan (BCP). A BCP shall be developed to include instructions needed to provide effective person centered care to each resident, based on his/her initial assessment and the professional standards of quality of care, to serve as a functional guide in delivery of care until such time as a comprehensive careplan is developed. R270's undated Face Sheet documents R270 admitted to facility on 10/31/24 with medical diagnoses of Wedge Compression Fracture of T9-T10 Vertebrae, Dementia, and Hypertension. R270's admission assessment dated [DATE] documents R270 is alert and oriented to person only. R270's Nurse Progress Note dated 11/4/24 at 5:42 AM documents 4:25 AM…

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 implement care planned post fall interventions for fall prevention. This failure affects one resident (R59) out of seven reviewed for falls on the sample list of 31. Findings include: On 11/6/24 at 10:43 AM, R59 was seated in her own room in a wheelchair. R59 had a power cord for a personal alarm hanging from the back of her wheelchair but the actual alarming module was not present. R59's Care Plan (undated) documents R59 experienced actual falls on 6/9/24 and 6/10/24. This care plan documents the post fall intervention from the fall on 6/9/24 was to provide an alarm on R59's wheelchair. R59's Nursing Progress Notes dated 6/9/24 documents R59 was seated in her wheelchair just prior to being noted on the floor sitting on her buttocks with her legs outstretched. R59's Nursing Progress Notes dated 6/10/24 documents R59 was sitting on her buttocks on the floor with her wheelchair next to her. On 11/6/24 at 11:00 AM, V4, Licensed Practical Nurse/ Care Plan Coordinator, reviewed R59's care plan and stated, Yes,…

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 maintain resident bed side rails in a safe condition. This failure affects one resident (R12) of five reviewed for bed side rails in the sample list of 31. Findings include: R12's medical diagnosis list (11/7/2024) documents R12's diagnoses include: Extrapyramidal and Movement Disorder, Left Knee Valgus Deformity (abnormal angle to the lower leg), and Dementia. R12's quarterly assessment (9/11/2024) documents R12 has impaired range of motion in both lower extremities. R12's Fall Risk Evaluation (9/11/2024) documents R12 has a recent history of falling in the facility. R12's Bed Rail Evaluation (9/11/2024) documents R12's bed side rail serves as an enabler to promote independence in entering and/or exiting R12's bed. R12's Care Plan (11/7/2024) documents R12 utilizes a bed side rail for mobility and staff should encourage R12 to use the side rail to promote R12's independence. On 11/6/2024 at 10:11AM, R12's half-length right side bed rail was in the upward position. The rail appeared loose and was leaning…

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 a resident's (R2) right to be free from abuse by another resident (R1). This failure affects three (R1, R2, R3) of seven residents reviewed for abuse in the sample list of seven. Findings include: The facility's Final Report dated 8/15/24 documents on 8/8/24 at 8:25 AM staff serving breakfast witnessed R2 grab R1's oatmeal and R1 hit R2 on the right side of R2's face with an open hand. R1 and R2 were immediately separated and there was no injury or redness noted. The investigative file for this incident included interviews with R3, V6 Certified Nursing Assistant (CNA) and V7 CNA that document they witnessed this incident and confirmed R2 grabbed R1's oatmeal and then R1 open handed smacked R2's face/head. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment and - BIMS 7, other behaviors occurred 1-3 days during review period. R2's MDS dated [DATE] documents R2 has short and long term memory loss. R2's Skin…

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 report an allegation of abuse to the administrator. This failure affects two (R2, R3) of seven residents reviewed for abuse in the sample list of seven. Findings include: On 8/20/24 at 9:39 AM R3 stated around a few weeks to a month ago R2 came into R3's room, R3 told R2 to leave R3's room which may have set (R2) off. R3 stated R2 then grabbed R3's wrist and R3 felt afraid of R2. R3 stated R3 staff responded to R3's call light and directed R2 out of R3's room, and R3 told V8 Certified Nursing Assistant (CNA) that R2 had grabbed R3's wrist. R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact. R2's MDS dated [DATE] documents R2 has short and long term memory loss and wandered one to three days during the seven day lookback period. On 8/20/24 at 9:53 AM V8 CNA stated a few weeks ago R2 was lying in R3's bed while R3 was in the room, and staff had to redirect R2 out of the room. V8 denied being told that R2 grabbed R3. On 8/20/24 at 10:55…

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 are free from significant medication errors, by failing to correctly identify a resident prior to medication administration. This failure affects one resident (R1) out of seven reviewed for medication administration. Findings include: R1's Face Sheet (undated) electronic Census Detail documents R1 was admitted to the facility for this residency on 9/28/23. R1's (undated) electronic Diagnoses List documents R1 experienced medical conditions including Congestive Heart Failure, Atrial Fibrillation, History of Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Anxiety, Hypertension, Coronary Artery Disease, and major Depression. R1's emergency room After Discharge Instructions dated 8/8/24 documents R1 was treated at the emergency room for an accidental medication overdose, requiring intravenous fluids, administration of intravenous Vitamin K 5 milligrams (mg) to reverse the effects of Coumadin (anticoagulant, blood thinner), 1,000 milliliters of normal saline, and oral…

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 operationalize their abuse prevention policy by failing to document identified interventions for five (R2, R3, R4, R5 and R6) of nine residents reviewed for abuse from a total sample list of nine residents reviewed. Findings include: The facility provided Abuse Prevention Program Policy dated 11/28/16 documents that the facility affirms the right of residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. 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 will be done by implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property by promptly and aggressively making the necessary changes to prevent future occurrences. Through the care planning process, staff will identify any problems, goals and approaches,which would reduce the changes 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 observation, interview, and record review the facility failed to ensure therapy services were provided for six residents (R2, R4, R19, R20, R21, R22) of six residents reviewed for therapy services on the sample list of 22. Findings include: 1. On 3/21/24 at 1:00 PM, R2 stated they quit giving R2 therapy and R2 does not know if they are going to start it again. R2 stated, when asked if R2 wants therapy, oh yes, I need to have it, I felt tremendously better when getting it. R2's Physician Order Sheet (POS) dated 12/1/23, documents Physical Therapy (PT) and Occupational Therapy (OT) evaluate and treat. R2's Therapy Past Appointments Sheet dated 2/19/24, documents (Therapy Provider) will no longer be the therapy provider starting 2/19/24. 2. On 3/21/24 at 12:42 PM, R4 stated R4 used to get therapy and then it just quit and R4 wants to resume therapy. R4 stated R4 needs that help because R4 has fallen and R4 has to get therapy. R4 stated they have not told R4 when therapy will start back up and that R4 has…

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 protect the resident's right to be free of verbal and physical abuse by another resident for two of three residents (R8 and R9) reviewed for abuse in the sample of 22. Findings include: The facility's abuse report dated 2/10/24, documents an altercation between R8 and R9. This report also documents R9 called R8 a derogatory name and R8 got up from her table and walked to R9's table and R8 pinched R9 on the right forearm. R8's current Electronic Medical Record (EMR) documents R8's diagnoses as: personal history of a Traumatic Brain Injury, Bipolar Disorder, and Depression. R8's Psychosocial Evaluation dated 1/3/24, documents R8 is easily distracted, has difficulty utilizing coping skills, difficulty with impulse control, difficulty with problem solving, has poor judgement, makes inappropriate comments, is depressed, anxious, and suspicious, and is physically aggressive. R8's Care Plan dated 3/12/24, documents R8 displays manipulative behaviors, is impatient, and has verbal outbursts. R9's current EMR documents R9's diagnoses…

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 follow physician discharge orders for two residents (R2, R3) of three residents reviewed for following physician discharge orders in the sample list of 22. Findings include: 1.) R2's current Electronic Medical Record (EMR) documents R2's diagnoses as: Osteomyelitis, wedge Compression Fracture of T11-T12 Vertebra subsequent encounter for fracture with routine healing, and Anemia. R2's Physician Order Sheet (POS) dated 1/1/24-1/31/24, documents Aspirin 81 milligrams (mg) oral tablet chewable, give one tablet by mouth one time a day and Apixaban (Eliquis) (anticoagulant-blood thinner) oral tablet 5 mg give one tablet by mouth two times a day with a start date of 11/1/23. There are no documented orders on this same POS to stop Apixaban (Eliquis) (anticoagulant) at any time. R2's Care Plan dated 2/27/24, documents R2 is on an anticoagulant. The Health Status Note dated 1/9/24 documents R2 had an unwitnessed fall in R2's room with a head laceration and R2 was sent the the Emergency Department. R2's Emergency Documentation notes…

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 maintain a properly functioning call light system for four (R1, R5, R6, R7) residents out of four residents reviewed for call lights in a sample list of seven residents. Findings include: 1. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as independent in decision making. On 11/30/23 at 1:20 PM R1's call light was activated by R1. R1's call light turned on a light above R1's door but was not audible. On 11/30/23 at 1:25 PM the Call Light System was not functioning as it was supposed to on the facility South Unit. South Unit call lights were observed with lights above the rooms but without sound. On 11/30/23 at 1:05 PM R1 stated What happens if I am in the shower or something and I fall. Who is going to come help me if they (staff) don't know the light is even on? We (residents) deserve to have it fixed. 2.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. On 11/30/23 at 11:38 PM R5's call light was…

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 the resident's right to be free from verbal and mental abuse by staff for two of four residents (R1, R2) reviewed for abuse in a sample list of seven residents. Findings include: The facility policy titled 'Abuse Prevention Program' dated 11/28/2016 documents the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. 1.) R1's undated Face Sheet documents R1 admitted to the facility on [DATE] with medical diagnoses of Major Depressive Disorder, Adjustment Disorder with mixed Anxiety and Depressed Mood, Borderline Personality Disorder, Trigeminal Autonomic Cephalgias, Malignant Neoplasm of Brain, and Post Traumatic Stress…

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 timely report allegations of abuse to the abuse coordinator for two of four residents (R1, R2) reviewed for abuse in a sample list of seven residents. Findings include: The facility policy titled 'Abuse Prevention Program' dated 11/28/2016 documents the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. Verbal abuse is the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the Administrator. Supervisors should immediately inform the administrator and his/her designated representative of all reports of potential/alleged…

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 a staff member was removed from resident care after an allegation of staff to resident abuse for one of one residents (R2) reviewed for abuse on the sample list of seven. Findings include: R2's Final Incident Report to the State Agency dated 10/20/23 documents On 10/16/23 (R2) self reported (V5) Certified Nurse Aide (CNA) called him a f. (R2) stated he had not reported to anyone prior. (R2) reported he was up at the nurses' station getting a snack when (V5) CNA called him a f, then (V6) Certified Nurse Aide (CNA) said 'he heard what you said.' (R2) states he is 99% sure (V5) was talking to him. (V7) Unit Aide stated (V5, V6) were talking on the phone to a male and heard (V5) start to say f but then stopped because she realized (R2) was there. On 12/1/23 at 1:30 PM R2 stated (V5) was on her personal cellular phone when I wheeled up to the nurses station (North Unit) where (V5) was standing on the phone. R2 stated (V5) knows I am gay. (V5) called me a f. (V5) tried to cover it up by saying she…

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 follow residents' rights by not allowing residents to receive their mail on Saturdays. This failure has the potential to affect all 77 residents residing in the facility. Findings include: Resident Council meeting held on 10/3/23 at 10:00 AM consisted of R72, R48, R21, and R10 (Resident Council President). All four residents stated they do not receive mail on Saturdays because there is no one from Activities here on the weekends to distribute it. On 10/4/23 at 9:00 AM, V12 Activity Director stated that they should be delivering mail on Saturdays. V12 stated that V12 is the only Activity person right now and V12 does not work on the weekends. On 10/04/23 at 9:04 AM, V1 Administrator stated that there is no one to pass out mail on the weekends so residents are not getting their mail on Saturdays. The Resident Census and Conditions of Residents report dated 10/2/23 documents 77 residents reside in the facility.

Based on observation, interview and record review the facility failed to post daily staffing. This failure has the potential to affect all 77 residents residing in facility. Findings include: The facility's Resident Census and Conditions of Residents report dated 10/2/23 documents 77 residents reside in facility. On 10/2/23 upon entry into the facility there was no posted staffing located anywhere in the lobby or office areas. On 10/4/23 at 8:30 AM, there is still no posted staffing located anywhere in the lobby or office areas of the facility. On 10/4/23 at 8:49 AM, V1 Administrator confirmed the daily staffing is not posted. V1 stated that it should be posted outside of V1's office in the lobby area. V1 stated that the night nurse is responsible for completing and posting it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to maintain resident rooms in a safe sanitary home like manner for five (R59, R53, R15, R42, R19) of 18 residents reviewed for environment in a sample list of 44 residents. Findings include: 1. On 10/2/23 at 10:00 AM, R15 and R19 were in their room watching TV. R15 was in the bed by the door. R19 was in the bed by the window. Between their beds was a third empty bed. This bed did not have a mattress and metal springs were exposed. A window type air conditioner was lying face down in the middle of the bed on top of the exposed springs. R19 stated That broken air conditioner has set there for weeks. I'm getting tired of looking at it. Would you want that in your bedroom? They put the new one in and just left it there. R19's Minimum Data Set, dated [DATE] documents R19 is cognitively intact. 2. On 10/2/23 at 10:00 AM, R42 and R59 were in their room watching TV. A small window unit air conditioner was in the window by R59's bed. The unit was not…

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.) R11's EHR documents R11's last completed and submitted Quarterly Minimum Data Set is dated 6/8/23. R11's Quarterly Minimum Data Set, dated [DATE] documents it is still in progress and has not been completed and submitted. Sections B, C, D and Q are incomplete on this assessment.Based on interview and record review the facility failed to complete quarterly Minimum Data Set assessments every three months for four (R53, R50, R11, R24) of 18 residents reviewed for Minimum Data Set assessments on the sample list of 44. Findings include: The facility's Comphrehensive Assessment/MDS (Minimum Data Set) policy with a revision dated of 11/1/2017 documents, The MDS shall be re-evaluated according to the following schedule. a. Quarterly-within 92 of previous ARD (Assessment Reference Date)/MDS. 1. R53's Electronic Health Record (EHR) documents an admission MDS was completed for R53 on 5/24/2023. R53's EHR documents R53's quarterly assessment was due on 8/23/23. This screen documents this annual assessment is still in…

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 complete comphrehensive minimum data set assessments within 14 days of admission and every 12 months for two (R27, R178) of 18 residents reviewed for Minimum Data Set assessments on the sample list of 44. Findings include: The facility's Comphrehensive Assessment/MDS (Minimum Data Set) policy with a revision date of 11/1/2017 documents, Each Resident residing in this facility for a full 14 days shall have a MDS initiated by the 13th day after admission, and a RAI (Resident Assessment Instrument) completed by the 14th day after admission. admission applies to: a. First admission to the facility, or b. Subsequent admissions to the facility. This policy also documents, The MDS shall be re-evaluated according to the following schedule. a. Quarterly-within 92 of previous ARD (Assessment Reference Date)/MDS b. Annually- within 366 days of previous Comprehensive ARD/MDS. 1. R27's Electronic Health Record documents R27's had an annual comphrehensive MDS…

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 develop a resident centered psychiatric treatment plan for serious mental illness for two (R70, R59) of three residents reviewed for PASARR screens in a sample list of 44 residents. Findings Include: 1. On 10/2/23 at 12:06 PM, R70 was in R70's room which was on a locked unit designated for individuals with serious mental illness. R70's Pre-admission Screening and Resident Review (PASRR) dated 6/7/23 documents R70 suffers from Schizophrenia and requires specialized mental health care to treat this condition. R70's medical record does not document an interdisciplinary treatment plan to address R70's serious mental illness. On 10/4/23 at 10:00 AM V4, Care Plan Coordinator stated she was not aware individuals diagnosed with mental illness had to have a treatment plan. 2. On 10/2/23 at 10:00 AM, R59 was watching television in R59's room which was on a locked unit designated for individuals with serious mental illness. R59's Pre-admission Screening and Resident Review (PASRR) dated 7/31/23 documents R59 suffers from…

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 develop care plans with interventions for cigarette smoking. This failure has the potential to affect two of two residents (R8, R54) reviewed for smoking in a sample list of 44 residents. Findings Include: 1. On 10/2/23 at 10:30AM R8 stated I am going out to smoke. R8 was observed receiving a cigarette which was to be lighted when he went to the smoking area. R8's Smoking evaluation dated 6/28/23 documents Smoking materials kept by staff and dispensed at designated times. R8's Care Plan updated 8/23/23 does not include interventions to address R8's smoking.2. On 10/02/23 at 10:50 AM, R54 was smoking cigarettes in the smoking area unsupervised. R54's smoking assessment dated [DATE] documents R54 requires supervision while smoking. R54's Electronic Health Record does not contain a care plan for smoking.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete psychotropic medication assessments for three (R49, R58, and R24) of five residents reviewed for psychotropic medications on the sample list of 44. Findings include: The facility's Psychotropic Medication policy with a revision date of 6/17/22 documents, 4. Initiate a Psychotropic Medication Quarterly Evaluation within 14 days of admission for those resident currently receiving psychotropic medication. 1. R49's Medication Administration Record (MAR) dated 10/1/23 through 10/31/23 documents R49 was admitted to the facility on [DATE]. This MAR documents R49 is receiving one 0.5 milligram (MG) tablet of Xanax (Antianxiety medication) three times a day, one 40 mg tablet of Paxil (Antidepressant one time a day, and one 100 mg tablet of Trazodone (antidepressant) at bedtime. This MAR documents R49's Xanax was ordered on 4/28/23, the Paxil was ordered on 4/29/23, and the Trazodone was ordered on 4/28/23. R49's medical record does not include an…

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 contact and droplet isolation and conduct a PCR (Polymerase chain reaction) test when respiratory symptoms were present and failed to post isolation signs for two of two (R67, R128) residents reviewed for isolation on the sample list of 44. Findings include: The facility's COVID-19 Control Measures policy with a revision date of 5/19/23 documents, 4. If a resident is displaying symptoms of COVID-19 and has an antigen test that is negative, the resident must be PCR (Polymerase chain reaction) tested and is to remain on TBP (transmission based precautions) until the test results are received. 1. On 10/3/23 from 9:00 AM to 3:00 PM, R67's bedroom door was open and R67 coughed forcefully all day long. R67's door room indicated that R67 was in isolation due to the cough. On 10/3/23 at 1:41 PM, V1 Administrator was notified that R67 had been coughing all day long. On 10/3/23 at 3:10 PM, a gown was hanging on the outside of R67's door. The door did not have a sign or indicate why a gown was hanging on 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.