Arcadia Care Bloomington

Based on interview and record review the facility failed to develop a Dementia specific plan of care for one of three residents (R2) reviewed for Dementia Services on the sample list of 47. Findings Include: R2's Medical Diagnoses List dated June 2026 documents R2 is diagnosed with Unspecified Dementia Unspecified Severity with other Behavioral Disturbances. On 6/02/2026 at 11:50 AM V2 confirmed R2 did not have a plan of care related to R2's Dementia diagnosis and R2 should have one. V2 confirmed a Dementia care plan was added on 6/1/26 after surveyor notified the facility there was no Dementia plan of care in R2's medical record.

Based on observation, interview, and record review, the facility failed to provide staff and resident access to an appropriate handwashing facility for one resident (R14) on contact isolation precautions and failed to implement and practice Enhanced Barrier Precautions for one (R39) of six reviewed for infection control in the sample list of 47 residents. Findings: 1. R14's undated Care Plan documented an admission date of 5/15/2026 and diagnosis of Enterocolitis due to Clostridioides Difficile infection. On 6/1/2026 at 9:14 AM, R14's room had contact isolation signage posted at the entrance. Upon entering the room, a noticeable fecal odor was present. A bedside commode was in the room along with designated receptacles for soiled linen and personal protective equipment (PPE) disposal. Upon removal of PPE, the bathroom door was locked and inaccessible, preventing access to a sink to wash hands. On 6/1/2026 at 9:15 AM, R14 stated R14 was on isolation precautions for suspected Clostridioides Difficile infection (C-Diff). R14 stated the bathroom had been locked by the facility and R14…

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 employ a full-time Director of Nursing to oversee nursing services, resulting in lack of supervision of nursing staff and inconsistent clinical oversight, which has the potential to affect the health and safety of all 88 residents. Findings include:On 4/23/26 at 09:00AM surveyor requested to interview the Director of Nursing (DON) and was informed by multiple staff members there is no DON at this time. On 5/4/26 at 12:35PM V3, Assistant Director of Nursing (ADON) stated the former DON had been terminated on an unknown date and there is currently no DON.On 4/28/26 V1, Administrator, provided a copy of the Facility Assessment that documents the facility will employee one (1) full time Director of Nurses. The Resident Roster dated April 23, 2026 documents 88 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 of two residents (R4, R5) reviewed for abuse in the sample list of five residents.Findings include:R5's Current Medical Record documents R5 has diagnoses of anxiety disorder, substance abuse disorder, major depressive disorder, oxygen dependence, frontal lobe and executive function deficit, anoxic brain injury, and traumatic brain injury.The Minimum Data Set, dated [DATE] documents R5 has moderate cognitive impairment.R4's Current Medical Record documents R4 has diagnoses of mood and bipolar disorder.The Minimum Data Set, dated [DATE] documents R4 has intact cognition.The Final Abuse Investigation dated 4/6/26 documents on 3/29/26 staff reported a resident to resident physical altercation between R4 and R5. The Investigation documents while a nurse was administering medications R5 got upset and angry with the nurse and was yelling and cursing and R4 tried 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 observation, interview and record review the facility failed to notify the physician of a change of condition for one (R11) of three residents reviewed for injury on the sample list of 16. Findings include:Review of R11's Care Plan dated 08/27/2025 documents an admission date of 08/26/2025. The same Care Plan documents diagnoses of Type 2 Diabetes Mellitus Without Complications, End Stage Renal Disease, Essential (Primary) Hypertension, Chronic Embolism And Thrombosis of Deep Veins of Lower Extremity, Cellulitis, Acquired Absence of Right Foot, Acquired Absence of Left Foot, Osteomyelitis, Mixed Conductive And Sensorineural Hearing Loss, Bilateral, Insomnia, and Peripheral Vascular Disease. The same Care Plan documents R11 requires assistance of one to two staff members for ambulation and ADL (Activity of Daily Living) care.On 4/24/26 at 09:30am R11 was laying in the bed with an undated/signed dressing applied to the right lower leg. On 4/24/26 at 10:17am V17, License Practical Nurse (LPN) confirmed R11's right lower leg was wrapped with a dressing that did not contain a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain then follow a physicians order for an injury for one (R11) of three reviewed for injuries in the sample list of 16. Review of R11's Care Plan dated 08/27/2025 documents an admission date of 08/26/2025. The same Care Plan documents diagnoses of Type 2 Diabetes Mellitus Without Complications, End Stage Renal Disease, Essential (Primary) Hypertension, Chronic Embolism And Thrombosis of Deep Veins of Lower Extremity, Cellulitis, Acquired Absence of Right Foot, Acquired Absence of Left Foot, Osteomyelitis, Mixed Conductive And Sensorineural Hearing Loss, Bilateral, Insomnia, and Peripheral Vascular Disease. The same Care Plan documents R11 requires assistance of one to two staff members for ambulation and ADL care.On 4/24/26 at 09:30am R11 was laying in the bed with an undated/signed dressing applied to the right lower leg.On 4/24/26 at 09:30am R11 stated on an unknown date R11 was bleeding and a nurse applied a dressing to the wound. R11 stated 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 have fall precautions in place for four of five (R4, R8, R10 and R11) residents reviewed for accidents in a sample of 24.Findings include:1.On 3/9/2026 at 11:30 AM R4 was lying crosswise on her bed, R4 was unable to rise from her bed, and the call light was not within her reach.R4's Minimum Data Set (MDS), dated [DATE], documents R4's cognition is moderately impaired.R4's current Care Plan, documents diagnoses of Hallucinations, unspecified and Alcohol dependence with alcohol-induced persisting Dementia. It also documents an intervention on 5/1/2025 of Be sure the resident's call light is within reach and encourage the resident to use it.2.On 3/10/2026 at 10:30 AM, R8 was lying in bed, and his call light was not in reach.R8's MDS, dated [DATE], documents R8 is rarely or never understood.R8's Care Plan, documents diagnoses of Other Seizures and Dementia in other diseases classified elsewhere, unspecified severity with other behavioral…

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 rooms in a safe and functional condition. This failure has the potential to affect all 94 residents residing in the facility.Findings include:On 12/3/25 at 1:49pm, the facility's shower room on the 100 hall was in a state of disarray. There were loose pieces of tile, a crack in the shower board, floor tile grout dirty with black substance, an orange substance (appears to be rust) along baseboard edges, peeling caulk, and a gray/black fuzzy substance appearing on the caulking on lower shower head wall. These blackened areas were in spotted arrangement with radiating strands and resembled mold. There was a bathtub in this room with hair, boxes of gloves, and a gait belt inside of it.On 12/3/25 at 2:45pm, the facility's shower room on the 400 hall was in a state of disarray. There was approximately two feet of baseboard detached from wall, black substance on caulk, an orange substance (appears to be rust) on the shower board, overall dirty appearing tiles, black substance on areas of floor…

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 provide timely laundry services to maintain residents personal clothing in a clean useable condition for six of eighteen residents (R10, R12, R13, R14, R16 and R17) reviewed for Homelike environment.Findings include:On 12/3/25 at 9:50 AM, three clean linen carts observed in laundry room, filled with residents clean laundered clothing awaiting delivery. On 12/4/25 at 9:45 AM, the same three clean linen carts observed in laundry room still awaiting to be delivered. On 12/4/25 at 9:31 AM, R12 stated that it takes a while to get you clothes back, and R12 sometimes goes to laundry and asks to get some clothes. On 12/4/25 at 9:45 AM, V5 Laundry Aide stated there is an issue with missing and late laundry, as you can see both washers and dryers are going, and we have three 55-gallon garbage container, and two laundry carts filled of dirty clothes. V5 stated there is also two carts of clean clothes that have been here since yesterday and need to be delivered to the residents. On 12/4/25 at 9:50 AM, V15 Laundry Aide…

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 linens and windowsills were clean and free from cobwebs and dirt for one of four residents (R5) reviewed for housekeeping on the sample list of six. Findings Include: R5's Quarterly Minimum Data Set assessment dated [DATE] documents R5 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Essential (Primary) Hypertension. This assessment documents R5 as cognitively intact. On 10/14/25 at 10:30 AM, dusty hanging cobwebs holding insects were accumulated all along the windowsill next to R5's bed. R5 was lying in bed watching television. Particles of dirt were on the top of the linens on R5's bed. On 10/14/2025 at 1:54 PM, V11 Housekeeping Supervisor walked into R5's room. V11confirmed the presence of the dusty hanging cobwebs holding insects that had accumulated all along the windowsill next to R5's bed. V11 stated R5's room needed to be cleaned better, and 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 a safe, sanitary, comfortable environment by providing inadequate supplies of toilet paper for residents and failing to maintain communal shower floors in a safe sanitary manner. This failure has the potential to affect all 92 residents who reside in the facility.Findings Include:The facility's daily census dated 8/19/25 documents 92 residents reside at the facility.On 8/19/25 at 11:28AM, R2 stated They have been out of toilet paper more than once. I keep some extra, so I have some. R2 had two rolls of toilet paper in his drawer. On 8/19/25 at 11:15AM, R1 stated for several days last week I had to have family members bring me some (toilet paper) or I would have been without toilet paper. On 8/19/25 at 11:35AM, R3 stated we ran out of toilet paper last week. We had to use whatever we could like napkins and tissues. We went days like that. It just made me feel disrespected and ignored. On 8/20/25 at 12:30PM, V5 (CNA) Certified Nurse's Aide and V6 CNA verified there was a shortage of toilet paper a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a safe home like comfortable environment for three residents (R1, R2, R3) reviewed for safe homelike environment in a sample list of three residents.Findings Include:R1's current diagnosis list includes the following diagnoses: Chronic Neuropathy, Anxiety, and Major Depression.MDS (Minimum Data Set) dated 6/30/25 documents R1 is cognitively intact.On 8/19/25 at 11:15 AM, R1 was in her bed watching TV. The windowsill was covered in dust, dead spiders, and ants. The edge of the baseboard in R1's bathroom was crusted with brown debris and there was an odor of urine present. R1 stated there had been no toilet paper for several days last week. R1 stated I had to get family to bring me toilet paper, or I would have been without toilet paper. R1 stated there are ants in here all the time they crawl on the walls and the window.R2's current diagnosis list includes the following diagnosis: Chronic Obstructive Pulmonary Disease, Congestive…

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 provide adequate pest control when ants were observed for one (R1) of three reviewed for pest control on the total sample of five. Findings include:The facility census report dated 8/19/25 documents 92 residents reside at the facility.R1's current diagnosis list includes the following diagnoses: Chronic Neuropathy, Anxiety, and Major Depression.MDS (Minimum Data Set) dated 6/30/25 documents R1 is cognitively intact.On 8/19/25 at 11:15 AM, R1 was in her bed watching TV. The windowsill was covered in dust, dead spiders, and ants. R1 stated there are ants in here all the time they crawl on the walls and the window.R2's current diagnosis list includes the following diagnosis: Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Diabetes, Anxiety, and Depression.R2's MDS (Minimum Data Set) dated 7/19/25 documents R2 is cognitively intact.On 8/19/25 at 11:28 AM, R2 was sitting up in his room in a wheelchair. The windowsills in R2's room were covered with dust and dead insects. R2 stated there are ants 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 interview and record review, the facility failed to protect a resident's right to be free from physical abuse. This failure resulted in R2 shoving R1 on the shoulders and a second incident of R2 slapping R1 on the head. This failure affects two residents (R1, R2) of three reviewed for abuse in the sample of five. Findings include: The facility Abuse Prevention and Reporting policy (September, 2024) documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. R1's Medical Diagnosis list (6/13/2025) documents R1's diagnoses include: Metabolic Encephalopathy (brain dysfunction resulting from metabolic problems), Major Depressive Disorder, and Severe Dementia. R1's Resident Assessment (5/8/2025) documents R1 has severely impaired cognition. R1's psychiatry notes (5/8/2025) document R1 resides on a locked dementia unit 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 interview and record review, the facility failed to thoroughly investigate and document allegations of resident-to-resident physical abuse. This failure affects two residents (R1, R2) of three reviewed for abuse in the sample of five. Findings include: The facility Abuse Prevention and Reporting policy (September, 2024) documents the facility will implement systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and make the necessary changes to prevent future occurrences. The same policy documents the facility final investigation report will contain the following: name, age, diagnosis, and mental status of the resident who was allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated; the original allegation (noting the day, time, location, specific allegation, alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence, and any noted injuries); a summary of facts determined during the process of the…

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

Based on interview and record review, the facility failed to fully document the details of resident-to-resident physical abuse allegations and investigations in residents' medical records. This failure affects two residents (R1, R2) of three reviewed for abuse in the sample of five. Findings include: 1. The facility abuse investigation file (5/27/2025) documents R2 approached V3 (Certified Nurse Aide) in the facility hallway on 5/19/2025 and requested V3 to remove R1 from the room R1 and R2 were sharing as roommates because R1 was allegedly urinating onto the floor. The same record documents V3 and R2 returned to R2's room where R1 was located followed by an altercation occurring between R1 and R2 and R2 stating to V3 get (R1) out of my room before I beat his (expletive). The investigation documents R2 then shoved R1 on the shoulders with both of R2's hands with R1 stumbling backwards and being intercepted by V3. The investigation file did not document the identity of who reported the allegation to the administrator, if other residents were interviewed about the alleged perpetrator,…

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 a clean environment in the dining room for 13 of 18 residents (R1, R3 and R8-R18) reviewed for a homelike environment on the sample list of 18. Findings include: The Facility's Resident Council Minutes dated 3/12/24, document one unknown resident complained that she does not think her room is being mopped or swept daily. On 3/24/25 at 11:38 AM, the garbage can in the small dining room on the 300 hall contained a dirty adult brief, and staff items such as a drinking cup and back pack were on the dining room table. On 3/24/24 at 11:36 AM, V4 Certified Nursing Assistant (CNA) stated they normally take the residents (300 Hall Residents) to the small dining room to eat, but it hasn't been cleaned because housekeeping is short on staff, so the residents are eating in their rooms. V4 further stated the 300 hall normally has a housekeeper clean once a week due to lack of housekeeping staff. On 3/24/25 at 1:25 PM, V9 Certified Nursing assistant stated the residents can only use the small dining room (300…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to be free of physical abuse by another resident for two of five residents (R3, R4) reviewed for abuse in the sample list of nine. Findings include: R3's Facility Census documents R3 was admitted to the facility on [DATE] and has the following medical diagnoses, Dementia, Major Depressive Disorder and Alcohol Abuse. R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview for Mental Status (BIMS) score no score due to R3 having severe cognitive impairment and not being able to participate in the interview. R3's Incident Note dated 2/21/25 at 12:05pm documents Staff alleged a physical altercation occurred between R3 and R4. Medical Doctor, R3 and R4's Power of Attorneys, and Ombudsman were notified. R4's Facility Census documents R4 was admitted to the facility on [DATE] and has the following medical diagnoses, Wernicke's Encephalopathy, Major Depressive Disorder and Anxiety Disorder. R4's Minimum Data Set…

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 immediately report an allegation of abuse to the State Agency for two of three residents (R3, R4) reviewed for Abuse in the sample of eight. Findings include: R3's Incident Note dated 2/21/25 at 12:05pm documents Staff alleged a physical altercation occurred between R3 and R4. Medical Doctor, R3 and R4's Power of Attorneys, and Ombudsman were notified. R4's Incident Note dated 2/21/25 at 12:05pm documents Staff alleged a physical altercation occurred between R3 and R4. Medical Doctor, R3 and R4's Power of Attorneys, and Ombudsman were notified. The facility's Abuse Investigations and R3 and R4's Electronic Medical Record dated 2-10-25 through 2-20-25 were reviewed and do not include evidence of R4's abuse allegation, that was reported to V8 Previous Administrator on 2/10/25, being reported to the State Agency. The Facility's Abuse Prevention Program policy dated September 2024 documents, Internal Investigation: Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois…

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 a sanitary, homelike, and comfortable environment in, shower rooms, resident rooms, and a dining room. These failures affect thirteen residents (R2, R8, R11, and R19 through R28) utilizing the shower room on the 100 Hall, nineteen residents (R4, R6, R7, R10, R12, and R29 through R42) utilizing the shower room on the 300 Hall Dementia Unit, seven residents (R3 and R13 through R18) who usually have meals in the small dining room, one resident (R6) with a hole in the drywall and missing paint in her room, and one resident (R12) with a padded floor mat adhered to the floor by food debris next to her bed. all from a total facility census of 83. Findings include: 1. On 2/18/25 at 2:25 PM, R6's room had an outside corner adjacent to the bathroom door which was missing paint in an area two inches wide by four feet high on both sides of the corner where there had previously been a plastic corner protector, along with a patch of missing paint approximately one foot vertical by seven inches horizontal,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents right to be free from mental and emotional abuse. This failure affects one (R1) resident out of three residents reviewed for abuse in the sample of 43. Findings include: The facilities Abuse Prevention and Reporting policy effective 9/2024 documents mental abuse is the use of verbal or nonverbal conduct which causes, or has the potential to cause, the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. When an allegation of abuse, exploitation, neglect, or mistreatment has occurred the Department of Public Health shall be informed by telephone or fax. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively impaired. R1 was unable to complete a brief interview for mental status and required a staff assessment indicating R1 experiences inattention and disorganized thinking, long term and short term memory problems, unable to recall staff faces, location of R1's room and the seasons.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report allegations of mental abuse for one (R1) of three residents reviewed for abuse out of a sample list of 43. Findings include: The facilities Abuse Prevention and Reporting policy effective 9/2024 documents mental abuse is the use of verbal or nonverbal conduct which causes, or has the potential to cause, the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. When an allegation of abuse, exploitation, neglect, or mistreatment has occurred the Department of Public Health shall be informed by telephone or fax. R1's Comprehensive Incident Fall assessment dated [DATE] at 10:30 PM, documents R1 sustained a witnessed fall coming out of the shower room into the hallway. The Assessment further documents R1 was walking out of the shower room and R1 attempted to grab V13 Certified Nursing Assistant by the neck, V13 blocked R1's hand then R1 tried to grab V13's arm, V13 pulled her arm back and R1 then stumbled into 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 interview and record review, the facility staff failed to wait for a licensed nurse assessment before standing a resident up after a witnessed fall. This failure affects one resident (R1) out of three reviewed for abuse allegations on the sample of 43. Findings include: The Facility's Fall Prevention Program policy revised 5/2022 documents a Fall Assessment will be completed after any fall. R1's Comprehensive Incident Fall assessment dated [DATE] at 10:30 PM documents R1 sustained a witnessed fall coming out of shower room into the hallway. On 2/13/25 at 1:40 PM, V8 Licensed Practical Nurse stated she walked onto the unit as R1 was falling onto the hallway floor. V8 stated that she told V12 and V13 Certified Nursing Assistants that she would be back to assess R1 and to stay with him until she was finished providing care for another resident. V8 stated when she came out into the hallway R1 was no longer laying on the floor and V13 told her that they put R1 to bed and he was fine. V8 further stated when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain residents' privacy while in their rooms from one resident (R1) who has wandering behaviors. This failure has the potential to affect 18 of 20 residents (R3-R20) reviewed for resident rights in the sample of 20. Findings include: The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities policy dated 11/2018 documents, Your rights to safety: Your facility must be safe, clean, comfortable, and homelike. You have the right to privacy. R1's MDS ((Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired and exhibits physical, verbal, and other behaviors directed towards others, that puts R1 and others at risk for physical illness or injury, and significantly intrudes on the privacy and activity of others. This same MDS also documents R1 wanders daily, and the wandering significantly intrudes on the privacy or activities of others. R1's Psychiatry Progress Note…

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

Based on observation, interview, and record review the facility failed to implement an ongoing program of activities daily and record the residents' attendance and levels of participation in activities, as instructed by the facility's Activities Program policy, for 19 of 20 residents (R1, R3-R20) reviewed for Activities in the sample of 20. Findings include: The facility's Activities Program policy dated 03/2024 documents, Purpose: To provide an ongoing program of activities designated to appeal to the residents' interests and to enhance his or her highest practicable level of physical, mental, and psychosocial well-being. Guidelines: The Activity Director, trained staff, or volunteer will: 1. Identify and involve each resident in an ongoing program of activities that is designed to appeal to his or her interests and needs. 3. A minimum of four-seven organized activities will be scheduled daily. 4. Provide programs for residents who will not, or cannot, effectively plan their own activities pursuits. 5. Provide for residents needing specialized or extended programs to enhance their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to prevent resident-to-resident verbal and physical abuse for three of three residents (R1, R2, R3) reviewed for Abuse in the sample of 20. Findings include: The facility's Abuse Prevention and Reporting policy dated 09/2024 documents, This facility affirms the right of our resident to be free abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental, and psychosocial well-being. R1's admission Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to follow their Abuse Policy to update the care plan and implement approaches to safely monitor and increase supervision of a resident with a history of aggressive behaviors to prevent resident-to-resident abuse for three of three residents (R1, R2, R3) reviewed for Abuse in the sample of 20. Findings include: The facility's Abuse Prevention and Reporting policy dated 09/2024 documents, This facility affirms the right of our resident to be free abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS (Minimum Data Set) Assessments, staff…

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 a resident of discharge from facility for one (R2) of one resident in a sample list of four residents reviewed for Facility Discharges. Findings include: The facilities Notice of Transfer and Discharge Policy revised 10/2022 documents prior to discharge the facility will notify the resident of the discharge and the reasons for discharge in writing. The notice of discharge will be made at least 30 days before the resident is transferred or discharged . The facilities undated Resident rights Policy documents before a facility discharges you they must prepare you to be sure your discharge is safe and appropriate. R2's admission Record dated 12/14/24 documents R2 was admitted to the facility 3/8/24 and discharged [DATE]. R2's Physician orders dated 11/27/24 at 3:52 PM, documents R2 no longer needs nursing home care or services. Give medications and explain how to take them. The same order documents V9 Medical Director will no longer follow R2, 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 sufficient Registered Nursing (RN) hours on two of fifteen days reviewed for RN staffing. This failure has the potential to affect all 84 residents in the facility. Findings include: The facility Nursing Daily Schedule (August 21, 2024 through September 4, 2024) document on Wednesday 8/21/24 and Wednesday 8/28/24, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 9/4/24 at 1:45pm, V2 Director of Nursing confirmed the hours listed on the facility nursing daily schedule were correct and the facility failed to have RN coverage on 8/21/24 and 8/28/24. The facility Resident Midnight Census dated 9/4/24 documents 84 residents reside in the facility.

Based on interview and record review, the facility failed to protect a residents right to be free from verbal abuse by a staff member. This failure affects one (R2) of four residents reviewed for abuse in the sample of six. Findings include: The facility's Abuse Prevention and Reporting Policy dated 8/2023 documents the facility affirms the right of its residents to be free from abuse or mistreatment by staff. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: harassing, mocking, insulting, ridiculing, threatening, and yelling or hovering over a resident with an intent to intimidate. The Abuse Investigation Report dated 8/1/24 documents on 7/27/24 during dinner, R2 asked V3 Dietary Aide if R2 could have something else to eat. V3 told R2 V3 did not make the food and ignored R2. The report further documents V3 said to R2 stop looking at me you fat ugly b (expletive). V6 Receptionist, Abuse…

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 transfer a resident (R3) with a mechanical lift with two people for one of three residents reviewed for falls in the sample list of three. Findings include: R3's Diagnosis list dated 7/31/24, documents R3's diagnoses as: Muscle Weakness, other abnormalities of Gait and Mobility, Difficulty Walking not elsewhere classified, Weakness, Osteoarthritis, unspecified site, and Morbid (severe) Obesity due to excess calories. R3's Clinical Summary dated 3/22/24, documents R3 has unsteady gait requiring supervision, requires substantial/maximal assist of a mechanical lift, and is dependent for chair/bed to chair transfers. R3's Fall Risk assessment dated [DATE], documents R3 has had 1-2 falls in the past three months, is chair bound, and not able to perform gait/balance assessment. R3's Care Plan dated 3/22/24, documents R3 requires a mechanical lift with two person assist to transfer between surfaces. R3's Witness Fall Report dated 5/18/24, documents: R3…

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 accurately document resident advance directives in the resident's medical record. This failure has the potential to affect one resident (R53) of 24 residents reviewed for advance directives on the sample list of 39. Findings include: R53's Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form was signed by R53's legal guardian on 2/5/2024 and documents R53 does want to be resuscitated during a medical emergency. R53's Care Plan (2/1/2024) documents R53's code status as Full Code. R53's Physician Orders (3/21/2024) document R53's code status as DNR (Do Not Resuscitate). On 3/25/24 at 12:04pm, V9 Licensed Practical Nurse (LPN) stated staff look in a resident's electronic medical record under Advanced Directives to view the resident's POLST in order to check code status. On 3/25/24 at 1:03pm, V11 MDS Coordinator stated R53's care plan has not been updated to reflect R53's change of code status. The facility's Advance Directives policy (3/2024) documents copies of the resident's Advanced Directive shall be 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete resident comprehensive assessments. This failure affects one resident (R31) of 24 residents reviewed for accuracy of assessments on the sample list of 39. Findings include: R31's Minimum Data Set (MDS) dated [DATE] documents R31's weight as 182 lbs (pounds). R31's MDS dated [DATE] documents R31's weight as 164 lbs. This same record further documents, Yes, not on a prescribed weight-loss regimen under weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. R31's MDS dated [DATE] documents documents R31's weight as 164 lbs. This same record further documents, Yes, not on a prescribed weight-loss regimen under weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. R31's Electronic Medical Record (EMR) documents R31's weights as follows: 9/1/23 - 166 lbs; 12/1/23 - 164 lbs; 3/1/24 - 168.5 lbs. On 3/25/24 at 3:44pm, V12 Dietary Manager stated V12 obtained R31's weights…

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 identify and report significant weight loss to the family and physician for one (R74) of four residents reviewed for nutrition in the sample list of 39. Findings include: R74's Facility Census documents R74 was admitted to the facility on [DATE] and has the following medical diagnoses: Non-Surgical Spiral Fracture of Shaft of Humerus Left Arm, Dementia, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Spondylosis, Acute Cystitis with Hematuria, Abnormalities of Gait and Balance, Lack of Coordination, Weakness, Difficulty in Walking, Protein-Calorie Malnutrition, Visual Hallucinations, Overactive Bladder, Major Depressive Disorder, Urinary Tract Infection, HTN, Hyperlipidemia, Repeated Falls, and Homicidal Ideations. R74's Care Plan dated 2/7/24 documents the following: R74 is at increased nutritional risk for nutritional risk related to Depression, Hypertension, Type 2 diabetes, and dementia. Goal: Tolerate diet as ordered. Maintain current weight…

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 residents were free from physical abuse by another resident. This failure affects two of three residents (R1, R2) reviewed for abuse in the sample list of eight. Findings include: The facility's Abuse Prevention and Reporting - Illinois with a review date of August, 2024 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The facility's Final Abuse Investigation Report dated 2/1/24 documents the Conclusion and Action Taken as V7 Licensed Practical Nurse was notified of an alleged physical altercation between R1 and R2. R2 reported that R1 thought R2 was making fun 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 report a resident fall to the resident's representative for one (R3) of three residents reviewed for falls in the sample list of nine. Findings include: R3's Minimum Data Set, dated [DATE] documents R3 has short and long term memory impairment. R3's Nursing Note dated 11/25/23 at 8:00 AM documents R3 was found on the floor of the common bathroom and R3's physician was notified. There is no documentation in R3's medical record that R3's Power of Attorney (V4) was notified of the fall. R3's Fall Investigation for fall on 11/25/23 at 7:57 AM, provided by V2 Director of Nursing, does not document V4 was notified of the fall. On 12/11/23 at 12:17 PM V2 stated the nurse is responsible for notifying the physician and resident's family of falls, and this should be documented in a progress note and/or the incident report. V2 confirmed there is no documentation V4 was notified of R3's fall on 11/25/23. The facility's Physician-Family Notification-Change in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a comprehensive care plan to include antiplatelet medication use and monitoring for one (R1) of three residents reviewed for falls in the sample list of nine. Findings include: R1's Minimum Data Set, dated [DATE] documents R1 receives an antiplatelet. R1's November 2023 Medication Administration Record documents R1 receives Plavix (antiplatelet, blood thinning medication) 75 Milligrams by mouth once daily as of 10/11/22. R1's Care Plan revised on 11/28/23 does not document Plavix use and interventions for monitoring for side effects/complications of this medication. On 12/11/23 at 1:26 PM V2 Director of Nursing stated blood thinning medications should be care planned with interventions of monitoring for side effects. V2 confirmed R1's care plan does not address Plavix use and interventions for monitoring.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify, document/assess, address, and report a change in condition for one (R5) of three residents reviewed for death in the sample list of nine. Findings include: On [DATE] at 12:06 PM V9 Certified Nursing Assistant (CNA) stated V9 remembers R5 was doing a lot of mumbling before R5 passed, and when R5 admitted to the facility R5 was talking clearly. On [DATE] at 11:59 AM V9 stated V9 noticed R5's speech changes while in the dining room with R5. V9 stated V9 talked to other unidentified CNAs and nurses who were aware of the changes in R5's speech. On [DATE] at 2:36 PM V22 Licensed Practical Nurse (LPN) stated V22 recalls R5, R5 was alert and oriented, and V22 last saw R5 two days prior to R5's death. V22 described R5 as being fine that day and was shocked to hear of R5's passing. On [DATE] at 2:53 PM V23 Registered Nurse stated V23 had taken care of R5, R5 was staying in bed a lot and R5 had two falls. V23 stated the week prior to R5's death, V23 had…

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 administer a seizure medication as ordered resulting in a significant medication error for one (R4) of three residents reviewed for medications in the sample list of nine. Findings include: R4's Hospital After Visit Summary dated 2/2/23 includes an order for Phenytoin (seizure medication) Extended Release 200 milligrams (mg) by mouth twice daily. R4's Hospital Records dated 2/2/23 at 2:04 PM documents one dose of Phenytoin was administered on 2/2/23. R4's admission assessment dated [DATE] documents R4 admitted to the facility at 4:45 PM. R4's February 2023 Medication Administration Record (MAR) does not document Phenytoin was initiated until 2/3/23. There is no documentation that R4 received the evening dose of Phenytoin or that the facility communicated with the physician, hospital, or pharmacy regarding this dose. On 12/11/23 at 12:17 PM V2 Director of Nursing stated the hospital sends a referral packet prior to the resident's admission. V2 stated if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete weekly wound assessments and obtain a physician order for wound treatment for one (R1) resident out of three residents reviewed for wounds in a sample list of three residents. Findings include: R1's undated Face Sheet documents medical diagnoses of Cerebral Infarction, Diabetes Mellitus Type II , Atherosclerosis of Left Leg Native Arteries, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant side, Essential Hypertension, Protein Calorie Malnutrition, Repeated Falls, Neuralgia and Neuritis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as having moderately impaired cognition. This same MDS documents R1 as requiring substantial/maximal assistance for toileting, dressing, personal hygiene, moderate assistance for bed mobility and that R1 uses a wheelchair for mobility. R1's Physician Order Sheet (POS) dated November 2023 documents physician orders starting 10/23/23 to cleanse R1's Left Great Toe skin tear…

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 prevent potential cross contamination during wound care for one (R2) resident out of three residents reviewed for wound care in a sample list of three residents. Findings include: R2's undated Face Sheet documents medical diagnoses of Cerebrovascular Disease, Vascular Dementia, Anemia, Paranoid Schizophrenia, Protein-Calorie Malnutrition and Palliative Care, and Wound on Right Hip. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as dependent on staff for assistance with toileting, bathing, dressing, personal hygiene and bed mobility. R2's Care Plan instructs staff to use two people to assist R2 in bed mobility, transfers, dressing, toileting and personal hygiene. R2's Physician Order Sheet (POS) dated November 2023 documents a physician order starting 9/19/23 to cleanse R2's Right Hip wound with wound cleanser, apply half strength bleach solution soaked gauze and apply…

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 provide the services of a Registered Nurse for eight consecutive hours seven days per week. This failure has the potential to affect all 84 residents residing in the facility. Findings include: On 10/13/23, 10/17/23, and 10/18/23, there were 24 residents residing on the facility's 300 hall memory care unit, requiring a high level of supervision. There were three residents placed on transmission based precautions requiring nursing management. There were two residents who received dialysis treatments also requiring nursing management. The facility's Daily Nurse Staffing Schedule, dated from 9/24/23 through 10/17/23 documented six days when the registered nurse hours did not meet the requirement for eight consecutive hours seven days per week. On 9/25/23 the registered nurse worked a total of five hours from 7:00 PM until midnight. On 9/26/23 there was one registered nurse working seven hours from midnight until 7:00 AM, and one registered nurse working another five hours from 7:00 PM until midnight, but…

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 protect the resident's right to be free from physical abuse by another resident. This failure affects one resident (R4) out of four reviewed for abuse on the sample of 22. Findings include: The facility's Preliminary 24 hour Abuse Investigation Report (Initial Report) to The Illinois Department of Public Health dated 10/12/23 documents an allegation of physical abuse with R5 as the alleged aggressor and R4 as the alleged victim. R5's Census Detail dated 10/18/23 documents R5 was admitted to the facility 5/22/17. R5's Diagnoses List dated 10/18/23 documents R5 experiences conditions including Schizophrenia, Schizoaffective Disorder Bipolar Type, Anxiety, Major Recurrent Depression, and a history of Traumatic Brain Injury. R5's Minimum Data Set, dated [DATE] documents R5 received a score of 8 out of a possible 15 for a Brief Interview for Mental Status, indicating moderate cognitive impairment for R5. R5's Nurses Notes of various dates…

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

Based on observation, interview, and record review the facility failed to post signage to indicate isolation precautions and failed to use appropriate Personal Protective Equipment (PPE) for one of three residents (R5) reviewed for COVID 19 (Human Coronavirus SARS CoV2) in a sample list of six residents. Findings Include: The facility's infection control policy states Residents with suspected or confirmed COVID 19 infection: Health Care Personnel who enter the room of a resident with suspected or confirmed SARS CoV2 infection should adhere to standard precautions and use a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. goggles or a face shield that covers the front and sides of the face). R5's progress note dated 7/30/2023 at 5:33PM document rapid COVID test done with positive result DON (Director of Nursing) and son notified. On 8/1/23 at 10:00AM V6 Licensed Practical Nurse (LPN) was at the nurse's station. R5's door was closed, but there were no signs in place 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.