Benton Rehabilitation and Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to offer and provide dental services for one of one resident (R28) reviewed for dental services in the sample of 32. Findings include: R28's electronic medical record (EMR) shows an admission date of 9/15/2024. In R28's EMR diagnoses includes but is not limited to dysarthria following cerebral infarction, anxiety disorder, other chronic pain, major depressive disorder, and alcohol abuse. R28 diagnoses did not contain any diagnosis related to dental/teeth issues. R28's MDS (Minimum Data Set) dated 3/19/25, section J documents no complaints of pain from R28. Section C of R28's MDS dated [DATE] indicates R28 had a (BIMS) brief interview for mental status score of 11, indicating moderate impaired cognition. R28's current care plan has no documentation of interventions for dental pain or a focus area of dental/teeth issues. R28's Physician's orders include a prescription for Oragel 20-0.26% 1 application dental every 6 hours as needed for 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 administer vaccinations resident previously had consented for, for 2 residents of 5 residents (R29 and R35) reviewed for immunizations in a sample of 32. Findings include: 1. R29's admission record documents an admission date of 05/08/24 with diagnoses including: protein calorie malnutrition, deaf/nonspeaking, major depressive disorder, adult failure to thrive, anxiety disorder, anorexia nervosa, and vitamin D deficiency. R29's Physician Order Sheet documents an order for: immunization: may have annual flu vaccine with consent unless contraindicated with an ordered date of 05/09/24 and end date listed as 'indefinite.' On 04/24/25 at 3:00 PM R29 who was alert and oriented to person, place and time stated, he has never signed a consent for influenza. R29 stated that he wouldn't mind getting the influenza vaccine. R29 stated he has never received the influenza vaccine since he has been at the facility. R29's Patient Consent form or Seasonal Influenza Vaccination dated 03/18/24 signed by V20 (family) documents: a check mark 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.

Based on observation, interview and record review, the facility failed to maintain the shower room on the South Hall in a clean and sanitary condition. This has the potential to affect 23 residents residing on the South Hall. Findings include: On 12/02/24 at 10:19am, the shower room B on the South hall was observed to have an area in the corner behind the toilet where there was a significant buildup of an unknown black substance. On 12/02/24 at 10:32am, R2 who was alert to person, place, and time, stated that the shower rooms could be cleaner at times. On 12/02/24 at 10:53am, R13 who was alert to person, place, and time, stated the facility was pretty dingy before they started painting around here and the bathrooms are often dirty and damp. On 12/02/24 at 11:02am, R11 who was alert to person and place, stated the bathrooms could use a good cleaning. On 12/02/24 at 11:43am, V3 (Housekeeping) took a rag that was damp with cleaner and attempted to wipe an area of black buildup in the corner by the toilet of shower room B on the South hall, it did not wipe off after multiple swipes. It…

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 manage, safeguard, and accurately account for residents trust funds and personal checking accounts for 50 residents (R1-R50) reviewed for resident trust fund accounts in the sample of 52. This past noncompliance occurred from 12/21/23 to 6/10/24. Findings include: A letter dated 6/10/24 addressed to IDPH (Illinois Department of Public Health) stated in part, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator was Business Office Manager (BOM), V3. V6 voiced some vague concerns regarding V3 and the resident trust fund. (V3) was immediately suspended pending the results of the investigation. The Medical Director, Ombudsman, and local Police Department were made…

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 maintain accurate records for residents trust funds and personal checking accounts for 50 residents (R1-R50) reviewed for resident trust fund accounts in the sample of 52. This past noncompliance occurred from 12/21/23 to 6/10/24. Findings include: A letter dated 6/10/24 addressed to IDPH (Illinois Department of Public Health) stated in part, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator was Business Office Manager (BOM), V3. V6 voiced some vague concerns regarding V3 and the resident trust fund. (V3) was immediately suspended pending the results of the investigation. The Medical Director, Ombudsman, and local Police Department were made aware, 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 interview and record review, the facility failed to perform a pre-employment background checks on the business office manager. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 4/22/21 to 6/10/24. Findings include: An IDPH (Illinois Department of Public Health) Notification Form dated 5/24/24 at 9:40am documented, Staff reported an allegation of misappropriation of resident property. Staff member immediately suspending pending the results of investigation. POA (Power of Attorney), MD (Medical Doctor), and Police notified. Final (Report) to follow. A letter dated 6/10/24 addressed to IDPH stated, This letter will serve as a follow up and final report to the initial report submitted on 05/24/2024 regarding an allegation of misappropriation of resident property. The facility was unable to identify a specific resident involved at the time of the initial allegation. On 05/24/2024 at approximately 9:30 am, Housekeeper (V6) reported an allegation of misappropriation of resident property. The alleged perpetrator 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, facility staff failed to immediately report to the Administrator an allegation of potential staff to resident misappropriation of funds. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 4/1/24 to 6/10/24. Findings include: On 8/7/24 at 8:20am, V6 (Housekeeper) stated in April 2024, a couple weeks after the Easter egg hunt for kids in the community, V7 (Housekeeping Supervisor) told V6 that eggs with cash in them had been left in V3's (Former Business Office Manager) office, but when the kids opened them later, there was no cash in them. V7 stated she believed V3 had taken the cash. V7 told V6, I better keep an eye on (R3's) trust account. V6 stated she is R3's POA (Power of Attorney), and he is unable to read or write. V6 stated she did not inform V1 (Former Administrator) of this immediately because she didn't want to accuse V3 if it wasn't true. V6 stated later in May date unknown, V6 wrote out a letter to V1 outlining her concerns and took it to V1. V6 stated she believed this…

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 begin an immediate investigation into an allegation of staff to resident misappropriation. This has the potential to affect all 46 residents living at the facility. This past noncompliance occurred from 5/23/24 to 6/10/24. Findings include: On 8/7/24 at 8:20am, V6 (Housekeeper) stated in April 2024, a couple weeks after the Easter egg hunt for kids in the community, V7 (Housekeeping Supervisor) told V6 that eggs with cash in them had been left in V3's (Former Business Office Manager) office, but when the kids opened them later, there was no cash in them. V7 stated she believed V3 had taken the cash. V7 told V6, I better keep an eye on (R3's) trust account. V6 stated she is R3's POA (Power of Attorney), and he is unable to read or write. V6 stated she did not inform V1 (Former Administrator) of this immediately because she didn't want to accuse V3 if it wasn't true. V6 stated later in May date unknown, V6 wrote out a letter to V1 outlining her concerns and took it to V1. V6 stated she believed this happened on a Thursday,…

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 8 consecutive hours per day/ 7 days a week. This failure has the potential to affect all 30 residents residing in this facility. The findings include: On 4/10/2024, at 2:30 PM, V2 (Director of Nursing) confirmed that they only have 1 Registered Nurse on staff. V2 stated that there was another registered nurse working in the facility but resigned last week. V2 stated she does not work the floor. V2 stated that the facility is working on hiring more registered nurses. V2 stated that the facility utilizes an outside agency to help maintain Registered Nurse (RN) coverage for 8 consecutive hours per day. Review of the Nursing Schedules from October 1st, 2023 through April 11, 2024 documents no RN coverage was provided at the facility on 10/1/23, 10/6/23, 10/7/23, 10/8/23, 11/17/23, 11/18/23, 11/19/23, 12/29/2023, 2/29/24, and 4/04/2024. On 4/08/2024, at 8:30 AM, observed V2 (DON) working in the facility. On 4/09/2024, at 8:30 AM, observed V23 (Agency RN) working in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the infection control program was followed using current standards of practice and per the facility policy for 7 of 8 (R6, R12, R13, R22, R24, R26, and R29) residents reviewed for infection control in the sample of 28. Findings Include: 1. On 04/08/24 at 12:50 PM, PPE (personal protective equipment) containers were noted sitting outside R2, R21, and R23's doors. There was no signage on these doors to indicate the type of transmission-based precautions these residents were on. V2 (DON/Director of Nurses) and V3 (Regional Consultant) stated there were no transmission-based precaution signs on those doors and they didn't know why the residents were on isolation precautions, or if they were. On 4/8/24 at 3:13 PM, V2 (DON/Director of Nursing) stated she wasn't sure why there were no signs posted on the door of R2, R21, and R23's rooms. V2 stated they are on enhanced precautions and the carts have been there since she started working 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.

Based on Interview and Record Review, the facility failed to provide Advanced Beneficiary Notice of Non-Coverage (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage/ SNFABN-CMS10055) for 2 of 3 residents (R2 and R26) reviewed for Beneficiary Protection Notification in the sample of 28. The findings include: 1. R2's face sheet documents diagnoses including: Hypertension, Hyperlipidemia, Anxiety Disorder, Depression, and Asthma. R2's face sheet documents an admission date of 06/04/21. R2's SNF Beneficiary Protection Notification Review form documents a discharge from Medicare Part A services prior to exhaustion of his benefit day allotment and a last covered day of Part A Services of 12/15/23. This form documents that a written notice of the resident's potential liability for a non-covered stay (SNFABN - CMS10055) form was not provided to R2 to explain her right to appeal the decision of discharge from Medicare Part A services prior to exhaustion of her benefit days. On 04/10/24 at 1:45 PM, V3 (Regional Consultant) stated they do not have the form (SNFABN - CMS…

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 obtain the Pre-admission Screening and Resident Review (PASRR) document for 1 of 5 resident (R29) reviewed for PASRR screening in a sample of 28. Findings include: R29's New admission Information Sheet (undated) documents an admission date of 03/01/24 with diagnoses including Cerebral Vascular Accident (CVA), Acute right middle cerebral artery cerebral infarction, Left Hemiparesis, Hypertension, Left bundle Branch, Hyperlipidemia, Diabetes Mellitus type 2, Seizure disorder, Chronic Obstructive Pulmonary Disease (COPD), history of tobacco use, Chronic post traumatic headache, wasting syndrome, drug dependence, depression, anxiety, Post Traumatic Stress Syndrome, and occlusion of both carotid arteries. R29's Minimum Data Set (MDS) dated [DATE] documents in Section C, a Brief Interview for Mental Status (BIMS) score of 11, indicating that R29 has moderate cognitive impairment. Section GG of the same MDS documents eating as not attempted due to medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to implement interventions to prevent and treat a pressure ulcer for 1 of 3 residents (R1) reviewed for pressure ulcers in a sample of 28. The findings include: R1's Profile Sheet documents that R1 was admitted to the facility on [DATE] with diagnoses including mixed receptive-expressive language disorder and unspecified intellectual disability. R1's Minimum Data Set (MDS) dated [DATE] documents Section C, Cognitive Skills for Decision Making, severely impaired-never/rarely/made decisions. Section GG, Functional Abilities and Goals, of the same MDS documents that R1 is dependent with eating, oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/off footwear, personal hygiene, bed mobility, and transfers. R1's Care Plan undated, documents Problem/Need of: High Risk for Pressure Ulcer per Braden Risk Assessment, incontinence, limited mobility, dependent on staff for meeting all needs, prone to skin tears, and Braden…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide physician ordered nutritional supplements to 2 of 5 (R1 and R4) residents reviewed for nutrition in a sample of 28. Findings include: 1. R1's Profile Sheet documents R1 was admitted to the facility on [DATE] with a diagnosis of mixed receptive-expressive language disorder, unspecified intellectual disabilities. R1's Minimum Data Set (MDS) dated [DATE] documents Section C, Cognitive Skills for Decision Making, severely impaired-never/rarely/made decisions. R1's Physician Order Sheet dated 04/01/24 documents nutritional shake TID (three times a day), 7:00 AM, 12:00 PM, and 5:00 PM with an order date of 03/23/23. On 04/08/24 between 11:15 AM and 1:00 PM, R1 did not receive a nutritional shake during lunch service. On 04/08/24 at 12:30 PM, V7 (Dietary Manager) stated everyone has been served. On 04/09/24 between 11:30 AM and 12:30 PM, R1 did not receive a nutritional shake during lunch service. On 09/09/24 at 12:30 PM, V7 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure placement was checked to enteral feeding prior to administering flush and feeding for 1 of 1 resident (R29) reviewed for enteral feedings in a sample of 28. Findings include: R29's New admission Information sheet, undated documents an admission date of 03/04/24 with diagnosis of Cerebral Vascular accident (CVA), Acute right middle cerebral artery cerebral infarction, Left Hemiparesis, Hypertension, Left bundle branch, Hyperlipidemia, diabetes mellitus type 2, seizure disorder, chronic obstructive pulmonary disease (COPD), history of tobacco use, Chronic post traumatic headache, wasting syndrome, drug dependence, depression, anxiety, Post Traumatic Stress syndrome, occlusion of both carotid arteries. R29's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief interview for mental status score of 11. Which indicated that R29 has some cognitive impairment. Section GG documents eating as not attempted due to medical condition, toileting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a menu that met residents nutritional needs for 1 of 1 (R16) residents reviewed for nutrition in the sample of 28. Findings Include: R16's Profile Face Sheet dated 8/3/23 documents R16 was admitted to the facility on [DATE]. R16's Cumulative Diagnosis Log documents diagnoses that include vitamin B and D deficiencies, atrial fibrillation, Alzheimer's disease, and congestive heart failure. R16's MDS (Minimum Data Set) dated 2/6/24 documents a BIMS (Brief Interview for Mental Status) score of 07, which indicates R16 has a moderate cognitive deficit. R16's Physician's Orders sheet dated 4/1/24 to 4/30/24 documents a diet order of Regular, Vegetarian. R16's Nutritional assessment dated [DATE] documents R16 is on a Regular, Vegetarian diet and documents R16's protein needs as 86 gm/day (grams/day). R16's undated current Care Plan documents a Problem/Need area of Potential risk for altered nutritional status and/or weight loss . This same…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide the diet as ordered for 1 (R25) of 5 residents reviewed for nutrition in a sample of 28. R25's Face sheet documents R25 is a male resident with a date of birth of [DATE] and an admission date of 08/16/23. R25's diagnosis in part: Hemiplegia following unspecified cerebvascular disease affecting right dominated, Essential hypertension, End stage renal disease, Hyperlipidemia, Type 2 diabetes with diabetic peripheral angiopathy, Unspecified sequelae of cerebral infarction, Unspecified systolic heart failure, Gastro-esophageal reflux disease without esophagitis, Peripheral vascular disease, Cerebral infarction, reduced mobility, Dysphagia, Muscle wasting and atrophy. R25's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 14 indicating R25 is cognitively intact. R25's Physician Order Sheet dated 04/01/24 documents dietary orders to include: double protein serving and no tomato products. 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 report an allegation of abuse to the state survey agency for 1 of 3 residents (R4) reviewed for abuse in the sample of 11. The findings include: On 12/8/23 at 10:00am V1 said she had not had any complaints of a staff member saying she hated a resident. On 12/8/23 at 1:00pm, V9 (Certified Nurse Assistant/CNA) said on 11/30/23 she did hear V10 (CNA) say that she hated R4 and refuse to change her one time when she was asked by V12 (former Activity Director). V9 said she reported it to the nurse on duty at that time. On 12/8/23 at 1:51pm, V12 said that V10 told her that she hated R4 and refused to change her when she asked her to. On 12/8/23 at 2:00pm, V1 (Administrator) said on or around 11/30/23, she did speak to V12 (former Activity Director) on the phone. V1 said that V12 was going on and on about policies and procedures and budgets and said she thinks V12 did tell her that V10 said she hated R4 and had refused to change her. V1 said that due to V12's erratic behavior, she did not believe it to be true. V1 said that 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 interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 11. The findings include: On 12/8/23 at 1:00pm, V9 (Certified Nurse Assistant/ CNA) said on 11/30/23 she did hear V10 (Certified Nurse Assistant) say that she hated R4 and refuse to change her one time when she was asked by V12 (former Activity Director). V9 said she reported it to the nurse on duty at that time. On 12/8/23 at 1:51pm, V12 said that V10 told her that she hated R4 and refused to change her when she asked her to. On 12/8/23 at 2:00pm, V1 (Administrator) said on or around 11/30/23, she did speak to V12 (former Activity Director) on the phone. V1 said that V12 was going on and on about policies and procedures and budgets and said she thinks V12 did tell her that V10 said she hated R4 and had refused to change her. V1 said that due to V12's erratic behavior, she did not believe it to be true. V1 said that she felt that V12 did not like R4 as she was wanting to put a baby gate up to keep R4 out…

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 a medication cart and enclosed narcotic box were kept locked and the keys remained with the nurse passing medications. This has the ability to affect all 30 residents living in the facility. Findings include: On 9/15/23 at 7:45am, V2 (Registered Nurse/RN) stated all the facility's residents are currently being housed on the South Hall due to renovations occurring on the North Hall. On 9/15/23 at 10:15am, V2 stated the only staff members who have keys to the medication room and the medication cart with enclosed narcotics box is the nurse who is passing medications that day. On 9/15/23 at 11:15am, V2 was observed passing medications on the South Hall. V2 prepared for administration of R2's medications. Afterward, V2 did not lock the medication cart or the narcotics box and walked into R2's room where the cart, still in the hallway, was not within V2's visual control. On 9/15/23 at 11:40am, V2 was observed preparing medications for administration to R7. V2 did not lock the cart or the narcotic box 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 interview and record review, the facility failed to provide a Director of Nursing for the facility and failed to have a Registered Nurse working 8 hours a day/7 day a week. This failure has the potential to affect all 29 residents residing in the facility. Findings Include: On 05/23/23 at 10:20 AM, V1 (Administrator) stated the facility currently does not have a Director of Nursing (DON) and has not since May 2023. V1 states the facility has sought to hire a DON and has had a couple interviews. V1 verified the accuracy of nursing schedules provided and stated the facility does not have any nursing waivers. V1 stated that V9 (Registered Nurse/RN) is the RN that works Monday-Friday, but she was injured on May 9, 2023 and has not yet returned. The May 2023 schedule documents that there was no RN coverage on 5/9/23-5/11/23, 5/15/23-5/18/23 and 5/22/23-5/25/25. On 5/25/23 at 1:00 PM, V1 confirmed there was not a RN to cover these shifts. On 5/26/23 at 9:00 AM, V11 (Registered Nurse) stated that they do not currently have a DON on staff and while V9 (RN) is out on an injury 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 observation, interview, and record review, the facility failed to maintain an environment free from urine odors on the South Hall. This has the potential to affect all 15 residents (R2, R3, R4, R5, R7, R8, R11, R12, R13, R14, R15, R16, R21, R23, and R283) living on the South Hall. The Findings Include: On 5/23/23 at 8:30am, a strong odor of stagnant urine was noted on the South Hall. The odor was noted from room XX to the nurse's station, which is located at the end of the South Hall. On 5/23/23 at 10:58am, R2 was alert only to herself. R2 smelled of body odor and urine. On 5/23/23 at 12:30pm, the urine odor on South Hall was still prevalent. On 05/24/23 at 7:50am, a strong odor of urine was again noted on the South Hall from room XX to the nurse's station. On 5/24/23 at 8:55am, R11, who was alert and oriented to person, place, and time, stated for about the past week when she goes out into the South Hall hallway, she can smell a strong urine odor. On 5/24/23 at 10:49am, R14, who was alert and oriented to person, place, and time, stated when he leaves his room, he notices…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to provide dependent residents with twice weekly showers for four residents of five residents (R1, R2, R10, R18) reviewed for ADL's (Activities of Daily Living) in the sample of 29. Findings include: 1. On 5/23/23 at 10:58am, R2 was alert only to herself. R2 smelled of body odor and urine, and R2's hair appeared matted. R2's Minimum Data Set (MDS) dated [DATE] documented that R2 requires physical help from at least one staff member for bathing. The South Hall Shower Schedule documented that R2 is to be showered on Tuesdays and Saturdays each week. R2's April 2023 Shower Sheets documented that R2 received showers on 4/1/23, 4/4/23, 4/8/23, and 4/18/23. There was no documentation to indicate that R2 received showers on the weeks of 4/9/23 and 4/23/23. R2's May 2023 Shower Sheets documented that R2 received showers on 5/2/23, 5/6/23, 5/9/23, and 5/16/23. There was no documentation to indicate that R2 received two showers on the weeks of 5/7/23 and 5/14/23.…

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 and interview, the facility failed to ensure that a resident's Physician's orders and POLST (Practitioner Orders for Life Sustaining Treatment) Forms match for 1 of 5 residents (R10) reviewed for Advance Directives in the sample of 29. The findings include: R10's Do Not Resuscitate (DNR) Practitioner Orders for Life Sustaining Treatment (POLST) Form note that R10 is a No Attempt Resuscitation. R10's Physician Orders dated 5/1/23-5/31/23 note an order for R10 being a FULL Code. On 5/24/23 at 9:36am, V10 (Regional Director of Operations) said that she would expect that the POLST Form and the physician's order would match. On 5/26/23 at 10:00 am, V6 (Quality Assurance Nurse) said that they go by the POLST and that they have a POLST book at the nursing station. V6 said that Social Service just updated the book.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify resident's representative in writing of hospital transfers for 2 of 2 residents (R10, R18) reviewed for hospitalizations in a sample of 29. Findings Include: 1. R18's Profile Face Sheet note that R18 was admitted to the facility on [DATE]. Profile Face Sheet list some of R18's diagnoses as unspecified protein-calorie malnutrition, acute kidney failure with tubular necrosis, type 2 diabetes mellitus with diabetic polyneuropathy. R18's MDS (Minimum Data Set) dated 4/30/23 note that R18 has a BIMS (Brief Interview of Mental Status) of 13 which indicates R18 is cognitively intact. Nurse's Note dated 4/29/23 document that R18 was sent to local emergency room after experiencing a fall and complaining of pain in her tailbone. Nurse's Note dated 05/24/23 at 09:25 am, notes R18 was sent to a local hospital on 4/26/23 for severe malnutrition and refusal to eat/drink, rapid decline in condition. On 5/24/23 at 11:30am, R18 said to her knowledge she did 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 Based on interview and record review, the facility failed to notify by mail the resident or resident's representative in writing of the notification of the facility bed hold policy for 2 of 2 residents (R10, R18) reviewed for hospitalizations in a sample of 29. Findings Include: 1. R18's Profile Face Sheet note that R18 was admitted to the facility on [DATE]. Profile Face Sheet list some of R18's diagnoses as unspecified protein-calorie malnutrition, acute kidney failure with tubular necrosis, type 2 diabetes mellitus with diabetic polyneuropathy. R18's MDS (Minimum Data Set) dated 4/30/23 note that R18 has a BIMS (Brief Interview of Mental Status) of 13 which indicates R18 is cognitively intact. Nurse's Note dated 4/29/23 document that R18 was sent to local emergency room after experiencing a fall and complaining of pain in her tailbone. Nurse's Note dated 05/24/23 at 09:25 am, notes R18 was sent to a local hospital on 4/26/23 for severe malnutrition and refusal to eat/drink, rapid decline in condition. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to add new fall prevention interventions for a resident at high risk for falls for 1 of 4 residents (R2) reviewed for falls in the sample of 29. Findings include: On 5/23/23 at 10:58am, R2 was in her room lying in bed. R2 was alert only to herself. R2's Face Sheet documented an admission date of 7/28/21, with diagnoses including Dementia without Behavior Disturbance, Osteoarthritis, Hypertension, and Muscle Weakness. A Fax Transmission Form dated 3/17/23 sent to R2's Physician on that date documented, Fell at 4:30am, no apparent injury. Slipped in urine going to the restroom. There was no corresponding Nursing Progress Note describing the fall. A Fall Investigation dated 3/17/23 at 4:29am documented, Resident was going into her room from the restroom, slipped in urine, had dribbled urine on floor prior to (going to the) restroom. (Found) resting on right buttock .on floor. What new intervention was implemented to prevent further falls? (Space left blank).…

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 that a resident was free from unnecessary psychotropic medications by not implement non-pharmacological interventions and behavior monitoring for 1 (R28) of 5 residents reviewed for unnecessary medication in a sample of 29. Findings include: R28's Profile Face Sheet documents R28 was admitted to the facility on [DATE]. R28's Diagnosis log (undated) documents diagnoses including panic disorder with Agoraphobia, Paranoid Schizophrenia, Generalized Anxiety disorder, Esophageal Dysphagia, Psychogenic Polydipsia, Vitamin D Deficiency, Sleep Disorder, Diabetes Mellitus Type 2, Transient Ischemic Attack (TIA), Suicidal Ideation, Anxiety, Depression and Neurocognitive Disorder. R28's Minimum Data Set (MDS) dated [DATE] documented the following: R28's admission date 2/1/23. R28's Brief interview for Mental Status Score was 14, indicating R28 is cognitively intact. R28 Mood Indicators document feeling down, depressed, or hopeless, trouble falling or…

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

Based on interview and observation, the facility failed to maintain call lights in working order for 1 of 3 residents (R1) reviewed for functioning call lights in the sample of 29. The findings include: On 5/23/23 at 2:18 PM, R1's call light appeared to be tied around the box on the wall. V3 (Speech Pathologist) reached for R1's call light to get it for him. V3 held up the call light button and said its broke. V3 said he is not sure how the call light button got broke. R1's call light was observed to not have the call light button on the end of the wire. There was nothing but wires on the end of the wire. On 5/23/23 at 2:18pm V4 (Maintenance Director) was observed replacing R1's call light button On 5/25/23 at 1:30pm, V10 (Regional Director of Operations) said that V4 checks all call lights every 6 months but she is going to change that to every month now. V10 said she cannot find a policy regarding call lights.