The Haven Of Bement.

Based on interview and record review the facility failed to have a policy to verify the identity of agency staff to ensure one (V28) of three CNA's (V18, V19) reviewed demonstrated competency in the skills and techniques necessary to care for residents. This failure resulted in a facility wide failure and effected all 39 residents in the building. Findings Include:The facility's Certified Nursing Job Description revised on 10/11/2024 documents, qualifications to perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements are to have a current certification as a Certified Nursing Assistant in accordance with the laws of the State of Illinois. On 1/9/2026 at 5:00PM, (Local County Sheriffs) were called to the facility for an altercation between two employees (V19 and V28). (Local County Sheriff's) report documented by V29 (Deputy Sheriff) states that V19 informed V29 that V28 was operating under a false name, V20, while working at the facility as a CNA. V1 then informed V29 that V28 was working for the facility under 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 Interview and Record Review the Facility failed to ensure Registry verification for one (V28) of three staff members reviewed for certification. This failure resulted with one (V28) working as a Certified Nursing Assistant while not certified. This failure affected all 39 residents residing at the facility. Findings Include: On 1/9/2026, V28 Certified Nursing Assistant (CNA) came to the facility and began working under the name of V20 CNA who was scheduled to work a shift at the facility as a Certified Nursing Assistant. After having a verbal altercation with V19 CNA, V28 confirmed that V28's identity was not V20. On 1/15/2026 at 11:05AM, V1 Administrator stated the facility uses a contracted agency to provide certified staff for employment as needed. V1 stated that V20 was scheduled to work 1/9/26. V28 came to work on 1/9/26 in the facility and provided V20's name as V28's own identity to be able to provide care and access the Electronic Medical Record. V1 stated V1 didn't report the incident to the state agency of the false identity and working of uncertified personnel…

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 notify the physician and family of the resident with a change in condition (weight loss) for two (R1, R8) of three residents reviewed for weight loss. Findings include:The facility policy Lab, Diagnostic Test Results and Change in Resident's Condition - Clinical Protocol Dated November 2016 documents to establish guidelines for physician notifications concerning resident lab and diagnostic tests results and change(s) in resident conditions. The policy further documents 2: The person who is to communicate results to a physician will review, compile the information and be prepared to discuss the following: a. the individual's current condition and any recent changes in status, including vital signs and mental status.The facility's undated Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol documents 1. Monitor and document the weight and nutritional status of residents in a format which permits readily available month-to-month comparisons. 2.…

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 report an altercation between two (V19 and V28) employees in presence of three (R6, R9 and R10) residents and failed to report that an unqualified individual was working as a Certified Nursing Assistant. Findings include:Documents from the (Local Sherriff's Department) documents that on 01/09/2026 V29 Sheriff Deputy (SD) was operating as a uniformed patrol for the (Local Sheriff's Office). At approximately 5:00PM, V29 SD was dispatched to the facility for a threats report. Dispatch informed V29 SD that they received a call from V18 Certified Nursing Assistant (CNA) who stated that one of the CNA's V18 was working with (V28, CNA) had threatened to beat her a (expletive) after V28's shift ends. Dispatch soon fielded a second 911 call from V28, CNA, regarding the incident. V29 SD arrived on scene and spoke with V18 CNA who stated the following, though not verbatim. V18 CNA stated that V28 CNA told V18 to meet V28 by the time clock so that V28 could beat her a (expletive). V18 CNA said that V28 CNA saying this caused 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review the facility failed to report to the police the misappropriation of ear buds in a timely manner for one (R3) of three residents on the sample list. Findings Include: On 11/6/2025 at 9:30PM, R3 reported to staff that R3's (ear buds) were missing from R3's room and the facility reported the misappropriation of goods to the state agency. On 11/14/2025 the final report from the state agency documents that on 11/6/2025 R3 went to put in R3's (ear buds) into the ear canal that R3 kept in a specific place when R3 realized the (ear buds) were not there. R3 utilized the (tracking) function on R3's cellular phone and the (ear buds) were pinged (located) at an address in (about 30 miles away). R3 asked one of the Certified Nursing Assistant on shift what her address was. The Certified Nursing Assistant stated she lives with her mom who is also a Certified Nursing Assistant at the facility and confirmed the address where the (ear buds) were located. The Facility Incident report 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 interview and record review, the facility failed to provide the services of a registered nurse for eight consecutive hours seven days per week. This failure has the potential to affect all 39 residents residing in the facility. Findings include:The facility's Staffing Postings dated 9/1/25 through 9/7/25 document there was not a registered nurse working in the facility on 9/1/25 nor 9/6/25.The facility Employee Roster (undated) documents two registered nurses employed by the facility, V4 Minimum Data Set Coordinator, and V8 Registered Nurse.On 9/12/25 at 12:50 PM, V1 Administrator, confirmed on 9/6/25 there was not a registered nurse on duty in the facility. V1 further stated on 9/1/25 there was a registered nurse who worked the overnight shift from 8/31/25 and was in the facility from midnight until approximately 7:40 AM which still falls short of the requirement of having eight hours of coverage. V1 then stated the facility had not been able to provide services such as intravenous medications due to the lack of a registered nurse to administer those types 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 sufficiently staff certified nursing assistants (CNAs). This failure affects four (R4, R18, R22, R31) of 16 residents reviewed for staffing in the sample list of 30. This failure has the potential to affect all 32 residents in the facility. Findings include: On 12/10/24 at 9:59 AM during the resident council meeting, R4, R18, R22, and R31 stated the facility does not have enough CNAs and they wait up to an hour for their call lights to be answered. R4 and R22 stated they have not been getting their showers which are scheduled twice per week. R4's Minimum Data Set (MDS) 10/1/24 documents R4 as cognitively intact and requires supervision/touching assistance to dependence on staff for activities of daily living (ADLs). R18's MDS dated [DATE] documents R18 as cognitively intact and requires setup/clean up to substantial/maximal assistance from staff for ADLs. R22's MDS dated [DATE] documents R22 as cognitively intact. On 12/10/24 between 3:00…

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 staff a full time Director of Nursing (DON). This failure has the potential to affect all 32 residents in the facility. Findings include: On 12/09/24, 12/10/24 and 12/11/24 between 9:15 AM and 4:00 PM there was no DON observed working in the facility. The facility's Facility Assessment with reviewed date 5/23/24 documents the facility will staff a full time DON. The facility's nurse schedule dated 11/23/24-12/15/24 does not document a full time DON. On 12/10/24 at 11:35 AM V1 Administrator stated the facility has been without a full time DON since December 2023. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 12/11/24 documents the resident census as 32.

Based on interview and record review, the facility failed to document registry verifications of nurse aide competency for five newly hired nurse aides prior to beginning employment in the facility. This failure has the potential to affect all 32 residents residing in the facility. Findings include: Facility employee files document the following staff hire dates: V11 on 10/17/2024, V12 on 10/21/2024, V22 on 10/4/2024, V23 on 11/6/2024, and V24 on 11/21/2024. The same records document the facility did not check the nurse aide registry for competency verification for V11, V12, V22, and V23 until 12/11/2024 and did not complete the check for V24 until 11/22/2024. On 12/12/2024 at 10:30AM, V1 (Administrator) reported the facility completed background checks for all staff prior to hire but the facility could not document the checks were done prior to staff beginning work in the facility. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/11/2024) documents 32 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 32 residents in the facility. Findings include: On 12/9/2024 at 9:34AM, V2 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V2 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V2 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V2 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or 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 maintain sanitary food storage areas. This failure has the potential to affect all 32 residents residing in the facility. Findings include: On 12/9/2024 at 9:341AM, the kitchen walk-in cooler flooring was soiled throughout with accumulations of dark colored decomposed food debris and spilled liquids. V2 (Dietary Manager) was present and reported not knowing the source of the liquids On 12/10/2024 at 12:20PM, the walk-in cooler remained as above. V2 was present and reported the food in the facility kitchen and cooler is available for all residents to eat. On 12/12/2024 during the noon lunch meal, the walk-in cooler remained as above. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/11/2024) documents 32 residents reside in the facility.

Based on interview and record review the facility failed to implement surveillance monitoring of resident infections and implement corrective measures, and failed to develop a water management plan that included the required risk assessment, control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. These failures have the potential to affect all 32 residents in the facility. Findings include: 1.) The facility's Infection Control Surveillance and Monitoring policy dated 7/18/23 documents to implement routine surveillance and monitoring which includes observing work practices to ensure appropriate use of protective clothing/equipment, improving training to prevent recurrence, directing correct procedures to prevent infections, and enforcing hand washing by all staff after resident care. This policy documents to update the infection control logs daily and analyze the data to identify trends and the need for additional controls to prevent further spread of infection. The facility's Resident Infection Control…

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 its antibiotic stewardship policy by failing to evaluate clinical data to ensure infection criteria and appropriate use of antibiotics. This failure has the potential to affect all 32 residents in the facility. Findings include: The facility's Antibiotic Stewardship Program dated 11/1/17 documents the purpose of the program is to improve the use of antibiotics and to reduce antibiotic resistance by implementing core elements which includes leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. This program includes a blank/incomplete checklist for the facility's Core Elements of Antibiotic Stewardship. The facility's Assessment of Infections and Antimicrobial Usage dated 11/1/17 documents to review and evaluate antimicrobial use monthly to determine whether criteria was met by determining whether the resident's documented signs and symptoms align with the recommended minimum criteria for initiating antibiotics, whether the infection met the Centers for Disease Control…

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 document and follow up on grievances for five (R4, R14, R18, R22, R31) of five residents reviewed for grievances in the sample list of 30. Findings include: The facility's Grievance Policy dated November 2016 documents residents and their representatives may file a grievance or complaint for concerns and the written grievances must be signed by the resident or the person filing the grievance on behalf of the resident. This policy documents grievances will be investigated within five working days, the administrator may delegate the department manager to investigate the grievance, the administrator will review the findings to determine if any corrective actions need to be taken, and the investigation findings and any corrective actions will be reported to the person who filed the grievance. This policy documents written grievance documentation will include the date the grievance was received, a summary statement, investigation steps, a summary of the findings, whether the grievance was confirmed, corrective actions taken, 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 serve pureed diets as planned on the menu. This failure affects three residents (R2, R7, R13) of four reviewed for pureed diets in the sample list of 30. Findings include: The facility Diet Type Report (12/9/2024) documents R2, R7, and R13 all receive a pureed diet during meals in the facility. The facility Diet Spreadsheet (11/11/2024) documents residents receiving pureed diets are to receive pureed bread with their lunch meal on 12/9/2024. The facility Diet Spreadsheet (11/12/2024) documents residents receiving pureed diets are to receive pureed sugar cookie with their lunch meal on 12/10/2024. On 12/9/2024 at 11:40AM, no pureed bread was visible among the prepared food items in the kitchen being served to residents at lunch. On 12/9/2024 at 11:50AM, R7 was seated at a table in the facility dining room eating a pureed meal. No pureed bread was present with R7's meal items. On 12/9/2024 at 12:00PM, V5 (Certified Nurse Aide) was feeding R2 lunch in the facility dining room. No pureed bread was present with…

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.) On 12/09/24 at 9:52 AM R8 was in R8's room and had approximately 1/4 inch long facial hair to chin and upper lip. On 12/9/24 at 3:02 PM R8's facial hair remained to upper lip and chin. On 12/10/24 at 1:23 PM R8 was in the dining room and facial hair remained to upper lip and chin. R8's Minimum Data Set (MDS) dated [DATE] documents R8 requires partial/moderate assistance for personal hygiene. R8's care plan dated 5/15/24 documents R8 has self care deficit with activities of daily living and prefers to have facial hair removed. This care plan includes to provide showers one to two times per week and ask resident preference, and assist R8 with grooming/shaving facial hair on shower days and as needed. R8's care plan does not document R8 is resistive to cares. The facility's master shower schedule documents R8's showers are scheduled on Wednesdays and Saturdays. On 12/10/24 at 1:43 PM V9 Licensed Practical Nurse stated the Certified Nursing Assistants (CNAs) are responsible for shaving residents and this should…

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 perform a mechanical lift transfer safely for one (R8) of one residents reviewed for transfers in the sample list of 30. Findings include: The Stand-Up Lift policy dated 10/30/08 documents to place the resident's feet on the foot stand and if the resident requires, secure the strap to stabilize the feet prior to raising the resident to a standing position. On 12/09/24 at 3:02 PM V11 Certified Nursing Assistant transferred R8 to and from the toilet with a mechanical sit to stand lift. V11 did not utilize the leg strap on the lift. R8's Minimum Data Set, dated [DATE] documents R8 has impaired range of motion to both legs and requires partial/moderate assistance from staff for toilet transfers. R8's Care Plan dated 5/15/24 documents R8 transfers with one staff person and gait belt. This care plan documents R8's diagnoses include epilepsy and dementia. This care plan does not document R8 uses a mechanical sit to stand lift and whether or 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.

Based on observation, interview, and record review the facility failed to replace an oxygen mask weekly, failed to store respiratory equipment in a manner to prevent cross contamination, failed to follow an intervention to re-insert a tracheostomy, failed to ensure a replacement tracheostomy was kept at bedside, and failed to administer oxygen per physician's order for two (R23, R24) of four residents reviewed for respiratory care on the sample list of 30. Findings include: The facility's oxygen policy with a review date of March of 2019 documents oxygen will be administered as ordered by the physician. This policy documents tracheostomy oxygen masks will be changed once a week. 1.) R23's tracheostomy care plan dated 1/3/24 documents R23 has a tracheostomy due to a total Laryngectomy. This care plan includes interventions to monitor R23 for removal of the tracheostomy and to encourage R23 to replace the tracheostomy. This care plan also includes an intervention to keep an extra tracheostomy tube and obturator at the bedside. On 12/09/24 at 9:29 AM, R23's tracheostomy oxygen mask 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.

Based on interview and record review the facility failed to ensure medications were available and administered as ordered resulting in significant medication errors for two (R8, R18) of 10 residents reviewed for medication administration in the sample list of 30. Findings include: The facility's Medication Administration policy dated 11/18/17 documents medications must be prepared and administered within one hour of the ordered time and record the medication administration on the Medication Administration Record (MAR) after after the medication is given. This policy documents to record on the MAR when a medication is not given and the reasoning, notify the physician as soon as practical when there is a missed dose of a scheduled medication, and if a medication is not available contact the pharmacy and then notify the physician of when the medication is expected to be available. 1.) R8's November 2024 MAR documents to administer Losartan Potassium 25 milligrams (mg) give half tablet by mouth once daily at 8:00 AM for hypertension (high blood pressure). This MAR documents R8'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer pneumococcal vaccinations and maintain vaccination documentation for three (R18, R19, R22) of five residents reviewed for immunizations in the sample list of 30. Findings include: The Centers for Disease Control and Prevention Pneumococcal Vaccine Timing for Adults dated 3/15/23 documents for adults age [AGE]-64, with no prior pneumococcal vaccinations, and who have chronic health conditions including Diabetes Mellitus, cigarette smoking, and chronic lung diseases, give PCV20 (Pneumococcal Conjugate Vaccine) or give PCV15 followed by PPSV23 (pneumococcal polysaccharide vaccine) at least eight weeks later. For adults over age [AGE] with only Prevnar13 vaccine, give PCV20 or PPSV23 a year or more after Prevnar13. For adults over age [AGE] with only PPSV23 vaccine, give PCV20 or PCV15 a year of more after PPSV23. The facility's Immunization of Residents policy dated 5/6/21 documents to offer the PCV13 or PPSV23 as indicated using the Pneumococcal…

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 report an allegation of misappropriation of medication for one resident (R1) of three residents reviewed for medications in the sample list of four. Findings include: On 11/19/24 at 11:25 AM, V3 Licensed Practical Nurse (LPN) stated V3 told V1 Administrator right after V3 saw R1's medications crushed in the garbage on 11/12/24 when V3 came in for 10 PM shift. V3 stated the second shift nurse was still passing medications when V3 came in for 3rd shift. V3 stated V6 agency nurse told V3 that V6 could not find the adapter for R1's gastrostomy tube (g-tube), that V6 has lost it. V3 stated V3 found a new adapter in the medication cart and that is when V3 saw the crushed medications in the garbage with R1's name on the little med cup. V3 stated all the medications in that little medication cup were crushed and they were white and pink. V3 stated she was going to take it out of the trash but went to do something first and when V3 returned to the cart, V6 had taken the trash bag already. V3 stated that's when she texted V1…

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 investigate a report of misappropriation of resident medication for one resident (R1) of three residents reviewed for medications in the sample list of four. Findings include: On 11/19/24 at 11:25 AM, V3 Licensed Practical Nurse (LPN) stated V3 told V1 administrator right after V3 saw R1's crushed medications in the garbage on 11/12/24 when V3 came in for V3's 10 PM shift. On 11/19/24 at 11:49 AM, V1 Administrator stated V1 did not follow up in the morning and forgot about it until surveyor just mentioned it to V1. V1 also stated V1 did not interview anyone, call anyone or do any type of report or investigation about it (report of misappropriation of resident medication). The facility's Abuse Prevention Program Policy dated Revised 11/28/2016, documents regardless of the specific nature of the allegation, the investigation shall consist of: a review of the initial written reports, completion of a written report on the status of the investigation of the occurrence, an interview with the person reporting the incident, 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 interview and record review, the facility failed to administer seizure medications to a resident with a seizure disorder requiring scheduled therapeutic medication monitoring. This failure affects one resident (R1) of three residents reviewed for significant medication errors in the sample list of four. Findings include: R1's current Electronic Medical Record (EMR) Medical Diagnoses documents R1's diagnosis as: Localization-related (focal) (partial) Idiopathic Epilepsy and Epilectic Syndromes with Seizures of localized onset, intractable, without Status Epilepticus. R1's current EMR Physician Order Sheet (POS) dated November 2024, documents R1's medications as: Levetiracetam Oral Solution 100 milligram/milliliter MG/ML, give 15 ml via percutaneous endoscopic gastrostomy (PEG)-Tube two times a day and Carbamazepine Oral Tablet Chewable 100 MG, give 1 tablet via PEG-Tube in the evening. This same POS documents keppra, vimpat, tegretol level every 6 months one time a day every 6 month(s) starting on the 1st or 1 day(s) related to Localization (focal) (partial) Idiopathic…

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 notify the physician of a resident's physical change of condition. This failure affects one of three residents (R1) reviewed for nursing care in the sample of three. Findings Include: The facility's Notification for Change in Resident Condition or Status dated 12/7/17 documents the facility staff shall promptly notify appropriate individuals (medical provider) of changes in the resident's medical/mental condition and/or status. R1's Medical Diagnoses list dated September 2024 documents R1 is diagnosed with Dementia, Covid-19, Heart Failure, Dissociative and Conversion Disorder, Major Depression, and Lewy Body Dementia. R1's Minimum Data Set, dated [DATE] documents R1 is severely cognitively impaired. R1's Medication Administration Record dated August 2024 documents R1's Risperdal (Antipsychotic) was increased on the afternoon of 8/22/24 from 0.5 milligrams two times per day to 2 milligrams two times per day due to uncontrollable behaviors and risk 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 protect the residents right to be free from physical abuse by another resident for two residents (R1, R2) of three reviewed for abuse in the sample of three. Findings include: The facility Abuse Prevention Program policy (2/2021) documents: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. The same record documents Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. R2's diagnosis list (6/27/2024) documents diagnoses including: Quadriplegia (paralysis of legs and arms), Epilepsy (seizure disorder), Cortical Blindness (visual blindness associated with brain damage), Profound Intellectual Disabilities, Cerebral Palsy, and Major Depressive Disorder. R2's Resident Assessment (6/6/2024) documents R2 has severely impaired cognition, is completely dependent on staff assistance to perform all activities of daily living, uses a wheelchair, and has left and right…

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 document a resident-to-resident physical abuse incident and investigation in a resident's medical record. This failure affects one resident (R2) of three reviewed for abuse in the sample of three. Findings include: The facility Resident Abuse incident investigation (6/16/2024) documents R1 and R2 were seated beside each other in the facility dining room on 6/16/2024 when R2 began making noises that agitated R1 and R1 proceeded to slap R2 on the thigh approximately 10 times. On 6/27/2024 at 10:30AM, R2's electronic medical record (undated) did not document any information of any type related to the 6/16/2024 altercation between R1 and R2. R2's nursing progress notes (June, 2024) did not document any information about R2 being the victim of physical abuse on 6/16/2024. On 6/27/2024 at 10:01AM, V1 reported V4 (Registered Nurse) only documented R1 and R2's 6/16/2024 incident in R1's medical record and not in R2's medical record.

Based on observation, interview and record review the facility failed to ensure therapy services were provided for five (R1, R2, R3, R4 and R5) of five residents reviewed for therapy services from a sample list of five residents. Findings include: 1. On 3/19/24 at 2:21PM, R1 was laying in bed and stated, I received a couple of rounds of therapy in February and then they said that they weren't going to be returning to the facility. I had sat on the edge of the bed for the first time in months right before they quit coming. I was improving. Now, they don't get me out of bed at all except for showers. I want to do therapy and they said that there would be others coming to do therapy, but they haven't come. R1's physical therapy notes dated 2/18/24 document R1 was sitting on the side of the bed with therapy. R1's physician orders dated 2/9/24 document R1 to have speech, occupational and physical therapy services. R1's occupational and physical therapy notes dated 2/11/24-2/17/24 document R1 was receiving services 5 days per week. R1's occupational and physical therapy notes 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 record review and interview the facility failed to provide a written Notice of Medicare Non-Coverage notice, (NOMNC) for two (R4 and R5) of three residents reviewed for Medicare Non-Coverage notices at least 48 hours prior to discharge from Medicare from the total sample list of five. Findings include: 1. R4's signed NOMNC, dated 2/20/24, documents that R4's physical and occupational therapy services will end on 2/20/24. 2. R5's signed NOMNC, dated 2/20/24, documents that R5's physical, occupational, and speech therapy services will end on 2/20/24. On 3/19/24 at 10:00AM, V1 Administrator stated that therapy services had stopped being provided for residents in the facility on February 19, 2024 and that on February 20, 2024 she directed her staff to provide NOMNCs to R4 and R5. On 3/19/24 at 3:30PM, V1 Administrator said that she knew that the 48 hour opportunity for appeal before discharge from Medicare was not met for R4 and R5.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to use the services of an RN eight consecutive hours Seven days a week and failed to designate a Registered Nurse to serve as a full-time Director of Nursing. This failure has the potential to affect all residents who reside at the facility. Findings include: The facility's Long Term Care Application for Medicare and Medicaid 1/8/24 documents 31 residents reside at the facility. The facility's RN (Registered Nurse) Schedule for December 2023 documents the facility did not have an RN in the facility on 12/25/23 or 12/30/23. The RN Schedule does not include a Director of Nursing (DON) . On 1/9/24 at 10:00AM V1, Administrator stated Our DON walked out without notice right before Christmas. We have had trouble keeping a DON. We have a Corporate Nurse who is here but not full-time. I am aware there were no RNs in the facility on 12/25/23 or 12/2023. The Facility assessment dated [DATE] documents Based on our resident population and their needs for 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.

Based on observation, interview and record review, the facility failed to ensure proper food storage and labeling to prevent potential food spoilage and resident illness. This failure has the potential to affect all 31 residents who reside in the facility. Findings include: The facility provided Refrigerator and Freezer Storage Policy dated 10/2014 documents 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 foods. Additionally, label refrigerated food prepared and held for more than 24 hours with the day/date by which the food shall be consumed or discarded (maximum of 7 days from time of preparation). On 1/8/24 at 9:40AM, V3 Dietary Manager said that all items are supposed to be dated upon delivery and dated again upon opening. Opened items are only supposed to be kept for 7 days. On 1/8/24 at 9:43AM, the following opened items were stored in the walk in cooler without proper labeling including; Maraschino Cherries dated 8/4/24, Salsa dated 11/6/24, Teriyaki Sauce 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 interview and record review the facility failed to have an Infection Preventionist working at the facility and overseeing the infection control program This failure has the potential to affect all 31 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 1/8/24 documents 31 residents reside in the facility. On 1/10/24 at 10:05 AM, V1 Administrator stated that they do not have a Director of Nursing and V2 Corporate Nurse is covering in the building occasionally and is available by phone. V1 stated V1 does not have V2's Infection Preventionist Certificate and confirmed V2 is not in the building regularly. On 1/10/24 at 10:46 AM, V1 stated that the previous Director of Nursing did not have the Infection Prevention Certificate either. The facility's Infection Control Surveillance and Monitoring policy with a reviewed date of 3/10/22 documents, Monitoring of the day to day operation of the Infection Control Program will be conducted by the DON (Director of Nursing).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the dignity of five (R11, R5, R6, R12, R17 and R27) of five residents reviewed for dignity from a total sample list of 24 residents reviewed. Findings include: The State of Illinois Ombudsman Program, Resident Rights in Long Term Care Facilities dated 11/2018 documents that all residents have a right to dignity and respect. R11's care plan dated 11/18/23 documents that R11 makes inappropriate comments toward others. R11's Minimum Data Set, dated [DATE] documents R11 as severely cognitively impaired. R11's Behavior monitoring and interventions Report documents R11 cussing on 12/2/23, 12/3/23, 12/6/23, and on 12/7/23. No behavior tracking was documented for R11 from 12/8/23 until 1/4/23. On 1/4/24, R11 was documented as having cussing behaviors. On 1/10/24 at 12:50PM, R17 stated, (R11) is so disrespectful and he will yell those things at anyone. I can't say it's abuse, but it is very disrespectful. On 01/08/24 at 3:00PM, R12 stated…

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 document the organisms being treated prior to initiating and/or continuing antibiotic therapy for four of four residents (R26, R85, R86, R29) reviewed for antibiotic stewardship in a sample list of 24. Findings include: The facility's Antibiotic Stewardship Program policy with a reviewed date of 12/10/21 documents, Purpose: To improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. The facility's Resident Infection Control and Antimicrobial Logs dated October 2023, November 2023 and December 2023 document the facility's residents with infections. The October 2023 log documents R29 had bacteria in the urine with an onset date of 10/4/23 and was treated with Nitrofurantoin (antibiotic). There is no organism identified for this infection. This log also documents R85 had a Urinary Tract Infection with an onset date 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 follow Physician orders to obtain daily weights for two residents with a diagnosis of Congestive Heart Failure for two of two residents (R24, R5) reviewed for Edema in the sample list of 24. Findings include: The facility's Conformance with Physician Medication Orders policy with a reviewed date of 9/27/17 documents orders prescribed by the Physician shall be completed as ordered. 1.) R24's Order Summary Report dated 1/9/24 documents a diagnosis of Chronic Diastolic Congestive Heart Failure. This Order Summary documents an order for daily weights and if there is a three pound increase in 24 hours or a five pound increase in seven days to contact the Physician with a start date of 12/22/23. R24's Medication Administration Record dated 12/1/23 through 12/31/23 documents R24's weights were not obtained on 12/21/23, 12/25/23 and 12/28/23. R24's Medication Administration Record dated 1/1/24 through 1/31/23 documents R24's weights were not obtained on 1/5/24…

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 Passive Range of Motion (PROM) to one resident (R28) admitted with contractures of one resident reviewed for Restorative Nursing in a sample list of 24. Findings include: R28's Physician's Order Sheet (POS) includes the following diagnoses: Spastic Quadriplegic Cerebral Palsy, Epilepsy, Malnutrition, Cortical Blindness, and Profound Intellectual Disabilities. R28's Physician's Progress Note dated 12/24/23 documents R28 is positive for contractures of extremities. R28's Plan of Care Response History dated 12/11/23 through 1/8/24 documents Passive Range of Motion to all extremities. Do five times to each extremity every shift. Of the 22 days PROMs were tracked PROMS were done on all shifts on 12/23/23 and 1/8/24 only. On 1/9/24 at 9:00AM V6 Registered Nurse (RN) Care Plan Coordinator stated If a resident has contractures I initiate a Care Plan for Range of Motion and the direct care staff are expected to do the range of motions and document it. If the order is for every shift, it should be documented every shift. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to properly manage a tracheostomy tube for one (R22) of one residents reviewed for tracheostomy tubes from a total sample list of 24 residents reviewed. Findings include The facility Tracheostomy Care Policy dated 3/29/2019 documents that tracheostomy care should be performed, once per shift or as often as required to maintain patency of the airway and minimize the risk of infection. A replacement tracheostomy tube is to be kept at the head of the bed at all times, clearly visible. The stoma is to be cleansed with sterile water and then dried. R22's undated diagnoses sheet includes: Chronic Obstructive Pulmonary Disease, Bronchitis, Tracheostomy, Anxiety, Depression, Type II Diabetes Mellitus, Coronary Artery Disease, Total Laryngectomy and Myocardial Infarction. R22's Minimum Data Set, dated [DATE] documents R22 as cognitively intact and currently receiving respiratory therapy treatments including oxygen therapy, suctioning and tracheostomy…

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 provide required physician's visits for one resident (R28) of one resident reviewed for physician's visits in a sample list of 24. Findings Include: R28's Physician's Order Sheet (POS) includes the following diagnoses: Spastic Quadriplegic Cerebral Palsy, Epilepsy, Malnutrition, Cortical Blindness, and Profound Intellectual Disabilities. The facility's Daily Midnight Census documents R28 was admitted to the facility on [DATE]. R28's admission orders and initial assessment were completed by the Nurse Practitioner. R28's Progress Notes document R28 was evaluated by the Nurse Practitioner monthly since admission. The first evaluation by V15, Medical Director is documented as 12/24/23 at 10:00AM. On 10/10/24 at 2:00PM V1, Administrator stated The company who provides our medical Director is in Chicago. (V15) or one of his associates visit periodically and are available by phone, but the Nurse Practitioner is here monthly or sometimes more often. I realize…

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 medications as ordered to keep the medication error rate below five percent (5%). There were two medication errors out of 25 opportunities resulting in a 8% error rate. This failure affects two residents (R13, R17) of seven residents reviewed for medications on the sample list of 24. Findings include: 1. R17's Medication Administration Record (MAR) for January 1, 2024 through January 31, 2024 includes a current physician's order for FIASP (Fast Acting Insulin Aspart) 100 UNIT/ML (milliliter) 3ML PEN {3 ML} Inject 4 units subcutaneously before meals (start of a meal or within 20 minutes after). On 1/9/24 at 4:00PM V10, Licensed Practical Nurse (LPN) administered R17's insulin. V10 did not prime the needle with two units of insulin. The manufacturer's insert for FIASP documents the Needle should be primed with two units prior to each injection. V10 stated I realized as soon as I injected the insulin I forgot to prime it. 2. R13's Medication Administration Record (MAR) for January 1, 2024 through…

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 a significant medication error for one resident (R28) of seven residents reviewed for medication in a sample list of 24. Findings include: R28's current Physician's Order Sheet (POS) includes the following diagnoses: Spastic Quadriplegic Cerebral Palsy, Epilepsy, Malnutrition, Cortical Blindness, and Profound Intellectual Disabilities. The POS documents a current physician's order for Temazepam (Hypnotic) Oral Capsule 15 MG Give 1 capsule by mouth in the evening related to insomnia. R28's Progress Note dated 1/4/24 at 5:34PM documents (R28) was given two doses of Temazepam by accident tonight at 5:00PM med-pass. (Physician) was notified and instructed (nurse) to monitor (R28) for 24 hours and if (R28) has a change in condition to call back. (R28's) vitals are Blood Pressure 123/64, Pulse 62, Oxygen Saturation 95%, Temperature 97.6 (degrees Fahrenheit). (R28) is resting peacefully in wheelchair by the nurse's station in eye sight of the nurse's desk at this moment. Will continue to Monitor. On 1/9/24 at 11:00AM V1,…

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 supervise a resident during toileting, failed to implement a post fall intervention for staff training, and failed to complete a fall investigation for two of three residents (R1, R3) reviewed for falls on the sample list of three. Findings include: The facility provided fall prevention policy dated 11/10/18 documents that immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. Documentation of the circumstances around the fall will be made along with new interventions. Fall assessments should be completed with any change of condition. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM (Assessment, Intercommunicate, Manage) for Wellness form along with any new intervention deemed to be appropriate at…

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.