Casey Rehab And Nursing

Based on observation, interview and record review the facility failed to properly label medications and failed to monitor expiration dates on medications administered for one (R4) resident out of nine residents reviewed for medication administration in a sample list of 27 residents. Findings include: The facility policy titled Administering Medications revised October 15, 2023 documents medications shall be administered according to Physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. The facility policy titled Storage, Labeling of Over the Counter Medication, Destruction and Disposal of Medication revised 11/9/2021 documents no discontinued, outdated or deteriorated medications shall be available for use in the facility. Expired medications are to be removed from areas medication carts prior to or at the time of expiration. Medications must be dated upon opening the container, however…

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 the resident record was complete for one (R48) resident out of one resident reviewed for closed records in a sample list of 27 residents. Findings include: R48's Electronic Medical Record (EMR) documents R48 was admitted to the facility on [DATE] and discharged on 10/21/24. R48's Electronic Medical Record (EMR) does not include Physician Orders, Nurse Progress Notes, Physician Progress Notes, Social Service Progress Notes, R48's weight and vital signs, Activities of Daily Living (ADL) charting and Assessments. On 1/14/25 at 2:00 PM V1 Administrator stated the facility is unable to provide documentation of R48's stay at facility due to a recent change in ownership. V1 stated R48 discharged on 10/21/24 to another skilled facility per R48's request. V1 Administrator stated whatever information is documented in the EMR is the only information the facility can provide. V1 stated R48's EMR is incomplete, and the facility has no paper documentation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to wear the proper Personal Protective Equipment (PPE) when providing feeding assistance and when administering medications to residents who are COVID-19 positive on Droplet and Contact Isolation Precautions for two of five residents (R38 and R20) reviewed for Infection Control in a sample list of 27 residents. Findings include: The facility policy titled Administering Medication revised 10/15/23 documents adherence to established facility infection control procedures shall be followed during the administration of medications. 1.) R20's Minimum Data Set (MDS) dated [DATE] documents R20 as severely cognitively impaired. This same MDS documents R20 is dependent on staff for assistance with eating. R20's Laboratory Report dated 1/6/25 documents R20 tested positive for COVID-19. R20's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 1/6/25 and ending 1/16/25 for (R20) of COVID Positive--COVID-19 Room. Isolate…

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 in servicing to staff members on the facility Quality Assurance Performance Improvement (QAPI) program. This failure has the potential to affect all 44 residents residing in facility. Findings include: The facility Daily Midnight Census dated 8/2/24 documents 44 residents residing in the facility. The undated facility Quality Assurance Performance Improvement (QAPI) Solution Revolution Policy documents QAPI includes all employees, all departments and all services provided. The facility educates staff on intervention and anticipation of resident's needs. A facility wide training will be conducted to inform everyone in the facility about the QAPI plan. These trainings will be conducted often and in multiple ways through regular all-staff meetings, department staff in-services, change of shifts report time. Dialogue, examples, exercise, etc. On 8/7/24 at 10:00 AM V22 Registered Nurse (RN) stated V22 has not received any training on the Quality Assurance Performance Improvement (QAPI) process. V22 RN stated, I think…

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 twelve hours of mandatory training for Certified Nurse Aides (CNA) yearly. This failure has the potential to affect all 44 residents residing in facility. Findings include: The facility Daily Midnight Census dated 8/2/24 documents 44 residents residing in facility. The facility Inservice Attendance sheets dated August 2023 through August 2024 do not document V27, V28, V29, V30 and V31 Certified Nurse Aide (CNA) have completed twelve hours of mandatory training. The facility provided documentation of employee hire dates and in-services documents the following: V27 Certified Nurse Aide (CNA) was hired on 5/25/2022 and has completed six hours of in-services in the past twelve months. V28 CNA was hired on 10/25/22 and has completed six hours of in-services in the past twelve months. V29 CNA was hired on 9/12/22 and has completed four hours of in-services in the past twelve months. V30 CNA was hired on 9/7/1994 and has completed eight hours of in-services in the past twelve months. V31 CNA was hired on 9/1/22 and has…

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

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 three of three residents (R1, R7, R8) reviewed for physical abuse on the sample list of 12. Findings include: The facility's Incident Report Form - Illinois Department of Public Health (IDPH) Notification dated 2/23/24, documents R8 was in the dining room when R8 reached out and made contact with R7's forehead. R7 and R8 were separated and assessed. R8's undated Face Sheet documents R8's diagnoses as: Unspecified Dementia, Unspecified Severity, with Psychotic Disturbance, Depression Unspecified, and Unspecified symptoms and signs involving Cognitive Functions and Awareness. R8's Minimum Data Set (MDS) dated [DATE], documents R8 is not cognitively intact. R8's Care Plan dated 2/27/24, documents R8 is known/has a history of displaying inappropriate behavior and has a history of hitting staff. R8's untitled document dated 1/4/24, documents R8 having behaviors which include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician orders to obtain a repeat Esophagogastroduodenoscopy (EGD) for one resident (R2) and failed to collect a urinalysis for one resident (R1). R1 and R2 are two of three residents reviewed for following physician orders in the sample list of 12. Findings include: 1.) R1's undated Cumulative Diagnosis Log documents R1's diagnoses as: Agitation due to Dementia, Major Neuro Cognitive Disorder, and Alzheimer's Disease probable with Behavioral Disturbances. R1's Minimum Data Set (MDS) dated [DATE], documents R1 is always incontinent of urine and requires assist with toileting. On 5/14/24 at 3:45 PM, V6 Licensed Practical Nurse (LPN) confirmed, labs (laboratory blood work) and a urinalysis (UA) were ordered for R1 on 4/28/24 at 6:20 PM. V6 stated the telephone order and blood draw information are put on the laboratory sheet and then night or day shift staff obtain the specimens. V6 stated she passed the information on to V7 LPN (night shift) who…

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

Based on observation, interview, and record review the facility failed to employ the services of a full time Director of Nursing. This failure has the potential to affect all 48 residents residing in the facility. Findings include: On 12/19/23 at 9:45 upon entrance to the facility, V1, Administrator was not available to complete the entrance conference. When asked to complete the entrance conference with the Director of Nursing (DON), V3, Environment Director stated the facility does not have a DON, and has not had a DON for months. On 12/19/23 at 10:05 am V2, Regional Director of Operations confirmed the facility does not have a Director of Nursing. On 12/19/23 and 12/20/23 there was not a Director of Nursing working in the facility. The facility's CMS-802 form dated 12/19/23 documents 48 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nursing. This failure has the potential to affect all 51 residents in the facility. Findings Include: On 12/5/2023 at 10:19 AM V1 Administrator confirmed the facility does not currently employ a Registered Nurse to serve as full time Director of Nursing. Upon survey entrance and throughout the survey (12/5/23- 12/8/23) there was no Director of Nursing present and employed by the facility. The facility's Facility assessment dated [DATE] documents a full time Director of Nursing is required in order to meet the resident's needs and provide competent support and care for the facility's resident population. The facility Long-Term Care Facility Application for Medicare and Medicaid dated 12/5/2023 documents 51 residents currently reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 51 residents in the facility. Findings Include: On 12/07/2023 at 11:45 AM V6 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V6 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V6 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V6 reported the facility dietician only works in the facility one day per month. V6 also denied being a certified Food Protection Manager, as required, for every person in charge of a food service. V6 denied: -being a dietician; -being a certified dietary manager; -having an…

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

Based on observation, interview, and record review the facility failed to prevent the potential for physical cross-contamination of food and failed to ensure dietary staff donned required hair restraints. These failures have the potential to affect all 51 residents in the facility. Findings Include: 1. On 12/5/2023 at 10:16 AM V7 (Dietary Aide) was working in the food preparation area of the facility kitchen without any required hair restraint. 2. On 12/7/2023 at 11:32 AM a can opener was mounted on a food prep table in the kitchen. The opener was soiled with accumulations of metal shavings where the cutting blade contacts canned food items being opened. The cutting surfaces of the opener blade felt dull when touched. On 12/7/2023 at 11:50 AM V6 (Dietary Manager) observed the above can opener and stated the opener definitely needs cleaned. On 12/7/2023 at 2:30 PM V6 reported food from the kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (12/5/2023) documents 51 residents reside in the facility.

Based on interview and record review, the facility failed to ensure required personnel attended the required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 51 residents in the facility. Findings include: The undated Quality Assurance Plan documents the facility Quality Assessment & Assurance (QAA) Committee should identify opportunities for improvement should be used to keep all QAA members, including the Administrator and Director of Nurses, up to date on what is going on within the facility. On 12/8/2022 V1 Administrator provided five QAA Meeting Sign-In Sheets (1/16/23, 4/10/23, 7/17/23, and 10/16/23) for the previous year's QAA meetings. The January, April, July, and October 2023 QAA Meeting Sign-In Sheets do not document the facility's Director of Nursing was present at any of the meetings. On 12/5/23 at 4:00 PM V1 Administrator confirmed the facility has not employed a Director of Nurses (DON) and therefor the facility has not had a DON at the last four Quality Assurance Committee Meetings held on 10/16/23,…

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 interview and record review the facility failed to map and identify high risk areas for Legionella growth, failed to formulate a prevention plan, failed to formulate a plan for any identified cases of Legionella, and failed to identify facility water outlets for testing samples. This failure has the potential to affect all 51 residents residing in the facility. Findings Include: On 12/7/23 at 1:53 PM V1 Administrator provided an undated Legionella Environmental Assessment Form. At 2:54 PM V12 Maintenance Director provided an undated floor plan map. The facility's floor plan map (undated) was a fire safety map showing the locations of fire walls, egress routes, smoke detectors, fire extinguishers, and sprinkler heads. V12 stated, I don't have a mapping to show the water distribution or high-risk areas for Legionella, I know where the city water comes into the building. The Legionella Environmental Assessment Form (undated) documented the facility characteristics, such as city water supply, number of buildings on the property, number of rooms, average length of stay,…

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 corridor handrails in sound and stable condition. This failure has the potential to affect all 51 residents in the facility. Findings Include: On 12/7/23 at 2:54 PM there was a one-foot section of handrail at the intersection of the two 200 halls which was loose and easily moveable up and down as well as rotating. There was a section of handrail between resident rooms [ROOM NUMBERS] which moved up and both directions sideways one and one-half inches, being unscrewed from the mounting bracket, and having screws protruding from the brackets. There was a section of handrail between resident rooms [ROOM NUMBERS] which had a loose mounting bracket that could be pushed one half inch recessed into the wall, allowing the handrail to move a commensurate amount, as well as having loose screws the length of the rail allowing the rail to be rotated. Between resident room [ROOM NUMBER] and the end of the corridor, the was a section of…

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

Based on observation, interview, and record review the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects throughout the facility kitchen areas. This failure had the potential to affect all 51 residents in the facility. Findings Include: On 12/5/2023 at 10:28 AM three or more flies resembling fruit flies were flying around and resting on the kitchen dishwasher drainboard areas. On 12/7/2023 at 11:45 AM five or more flies resembling fruit flies were flying around and resting on the kitchen dishwasher drainboard areas. An additional fly surfaced and flew out of a nearby floor drain. The floor drain contained standing water and the interior pipe surface above the water was soiled with dark colored accumulations of debris. V6 (Dietary Manager) was present and stated the kitchen floor drains are the problem (causing the flies in the kitchen areas) and they (the flies) are so bad. Facility pest control contractor treatment reports (September-November 2023) document flies were present in the facility kitchen during each month from…

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

Based on interview and record review, the facility failed to issue required quarterly account statements for a resident trust fund account. This failure affects one resident (R11) of one reviewed for trust funds on the sample list of 27. Findings Include: On 12/6/2023 at 11:56 AM, R11 reported having a resident trust fund account in the facility and not receiving any quarterly financial statements. On 12/6/2023 at 2:39 PM, V10 (Business Office Manager) reported starting employment in the facility during February 2023 and since that time not providing R11 with trust fund quarterly statements. V10 reported knowing V10 needs to learn how to produce the statements. V10 reported historically V10 just provided residents their account balances upon request. V10 reported R11 handles R11's own finances in the facility. R11's admission Checklist (9/14/2021) documents R11 authorized the facility to hold R11's personal funds in a resident trust fund account with the facility. The facility Personal Funds Authorization (undated) documents the facility will provide residents with trust fund…

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 timely complete the Preadmission Screening and Resident Review (PASARR) Level-1 screening and failed to complete the recommended Level-2 screening for one of one residents (R47) reviewed for required screenings on the sample list of 27. Findings Include: R47's Physician Order Sheet (POS), dated December 2023, documents R47 was admitted into the facility on 4/26/23 and has medical diagnoses of Sever Bipolar Disorder with Psychotic Features and Dementia with Behavioral Disturbances. The undated Maximus computer screen-shot documents R47's Level-1 PASARR screen was submitted on 8/9/23. R47's Notice of PASARR Level-1 Screen Outcome documents R47's Level-1 Screening results were received by the facility on 12/6/23 and recommended R47 be referred for a Level-2 screening due to Mental Health Disability. On 12/07/23 at 10:45 AM V1 Administrator stated R47 was first admitted on [DATE]. The Level 1 PASARR was not submitted to be completed until 8/9/23 and those…

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 physician ordered fall prevention interventions. This failure affects one resident (R8) out of six reviewed for falls on the sample list of 27. Findings Include: R8's current Physician Order Sheet, dated for December 2023 documents a physician order for R8 to have a bed and chair pressure alarm. On 12/5/23 at 10:31 AM, R8 was seated in a wheelchair in the facility Family Room. There was not any alarm on R8's wheelchair. V2 Assistant Director of Nursing stated, We are using a pommel cushion in (R8's) wheelchair so we don't have a double restraint. I think the chair alarm maybe refers to a recliner. On 12/5/23 at 10:58 AM, R8's room did not contain any kind of a chair, including a recliner. On 12/6/23 at 3:38 PM V2 stated, The pommel cushion does not prevent (R8) from standing up (not a restraint), she does it all the time. V2 further stated, The pressure alarm did not prevent (R8) from standing up (also not a restraint), she will stand up regardless. R8's Care Plan for Falls dated from 12/12/19…

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 properly clean and maintain a Continuous Positive Airway Pressure (CPAP) machine and mask for one of one residents (R43) reviewed for respiratory care on the sample list of 27. Findings Include: The facility's Bilevel Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) policy dated 3/8/13 documents CPAP machines provide continuous positive pressure to the airways of spontaneously breathing residents. Machine circuits are to be cleaned every week and as needed. External filters should be cleaned once a week and as needed. R43's Physician Order Sheet (POS) dated December 2023 documents R43 is diagnosed with Aspiration Pneumonia, Quadriplegia, Seizures, Altered Mental Status, and Mild Cognitive Impairment. R43 has an order to use a Continuous Positive Airway Pressure (CPAP) machine at bedtime. On 12/5/23 at 11:40 AM R43's Continuous Positive Airway Pressure (CPAP) mask was stored in a plastic bag however the mask was visibly soiled and had white debris all over the inside of the mask. 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 obtain a physician's rationale for declining a Registered Pharmacist recommendation to reduce the dosage of an Anti-depressant/ sedative (Trazodone). This failure affects one resident (R35) out of five reviewed for psychotropic and unnecessary medications on the sample list of 27. Findings Include: R35's Pharmacist Consultation Report dated 7/26/23 documents the facility's Registered Pharmacist gave the facility a reminder that V13, Nurse Practitioner, had declined to accept the Pharmacist recommendation to decrease Trazodone on 6/22/23, but had not provided a rationale as a basis for disagreeing with the recommendation. On 12/7/23 at 2:09 PM, V1 Administrator stated, Here is the return form from V13. This return form with a rationale was dated 8/11/23, 46 days after the initial recommendation from the Pharmacist.

Based on observation, interview, and record review the facility failed to maintain resident bed side rails in a safe condition. This failure affects one resident (R2) of 12 reviewed for bed side rails in the sample list of 27. Findings include: On 12/5/2023 at 11:52 AM R2 was resting in bed with the left (room side) half-length side rail raised in the upward position. The rail vertical supports were spaced 7.5-8.5 apart. R2 reported using the rail for bed mobility and positioning. On 12/8/2023 at 10:02 AM R2 remained in bed with the side rail in the raised position. V11 (Licensed Practical Nurse) was present and observed the spacing on the vertical supports on the rail and confirmed the spacing of the supports was a hazard. R2's undated medical diagnosis list documents R2's medical diagnoses include Physical Debility and Sleep Apnea. R2's comprehensive assessment (9/19/2023) documents R2 has impaired range of motion in bilateral upper and lower extremities. R2's Physician Orders (December 2023) documents R2 uses oxygen via nasal cannula tubing. This creates an additional…

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 employ a Registered Nurse to serve as full time Director of Nurses. This failure has the potential to affect all 53 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (10/31/23- 11/2/23) there was no Director of Nurses present and employed by the facility. On 11/2/23 at 12:00 PM V1 Administrator confirmed the facility does not currently employ a full time Director of Nurses. V1 confirmed the facility census is currently 53 residents. The facility's Facility assessment dated [DATE] documents a full time Director of Nurses is required in order to meet the resident's needs and provide competent support and care for the facility's resident population.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the dignity of one (R1) resident by leaving R1's soiled bedpan in plain view when not in use. This failure affects one (R1) resident out of three residents reviewed for dignity in a sample list of three residents. Findings include: R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has clear comprehension and can make self understood. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, eating, toileting, personal hygiene and extensive assistance of two people for dressing. On 11/2/23 at 10:30 AM R1 was lying in bed looking towards end of bed. R1's bedpan with remnants of stool inside bedpan was sitting on top of R1's suitcase at end of bed. R1's bedpan was not covered in any way and in plain view for visitors passing by with R1's door wide open. On 11/2/23 at 10:35 AM V20 Licensed Practical Nurse (LPN) placed R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident preferences were being honored for one (R1) resident by serving R1 red meats and not providing two baths per week. This failure affects one (R1) resident out of three residents reviewed for resident preferences in a sample list of three residents. Findings include: R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has clear comprehension and can make self understood. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, eating, toileting, personal hygiene and extensive assistance of two people for dressing. R1's Care Plan documents an intervention dated 8/11/23 for staff to offer appropriate subs for foods not eaten. An intervention dated 8/11/23 for R1 to receive a bath two times per week. This same care plan instructs staff to provide bathing, hygiene, dressing and grooming per resident's preference as…

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 follow a Physician order to timely obtain a Urinalysis (U/A) with Culture and Sensitivity (C&S) and failed to provide complete incontinence care for one (R1) resident out of three residents reviewed for Urinary Tract Infections (UTI) in a sample list of three residents. Findings include: R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has clear comprehension and can make self understood. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, eating, toileting, personal hygiene and extensive assistance of two people for dressing. R1's Physician Order Sheet (POS) dated September 2023 documents R1 was prescribed Levaquin (antibiotic) 750 milligrams (mg) daily for five days for UTI. The facility no rinse perineal cleanser label documents, Disperse foam onto areas needing cleansing, then wipe the area clean, repeating until skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to change the oxygen tubing and humidifier bottle for two of three residents (R2, R3) and failed to properly store a Bilevel Positive Airway Pressure (BiPap) mask for one of three residents (R1) reviewed for respiratory care on the sample list of three. Findings include: The Oxygen Therapy policy dated August 2003 documents oxygen tubing should be changed on a weekly basis and the tubing changes should be dated and documented on the residents Treatment Administration Record (TAR). When using prefilled humidification, staff should date bottles when changed and changes need to be documented on the TAR. 1. R2's Physician Order Sheet (POS) dated November 2023 documents R2 is diagnosed with Acute on Chronic Respiratory Failure, Bilateral Pneumonia, and Chronic Obstructive Pulmonary Disease Exacerbation. The same POS documents an order for Oxygen at three liters nasal cannula to maintain an oxygen saturation at 90 percent or above. On 11/1/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent cross contamination during wound care and perineal care for one (R1) resident out of three residents reviewed in a sample list of three residents. Findings include: The facility policy titled 'Aseptic Wound and Skin Treatment Procedure' reviewed 3/16/23 documents the purpose is to prevent contamination of the wound, protect wound from mechanical injury, to stimulate, restore and promote circulation and healing, prevent further deterioration of skin tissue, prevent necrosis of deeper body structures and to promote resident comfort. Procedure: pull privacy curtain and close door to resident room, wash your hands, establish your clean and dirty fields. Put on gloves and remove soiled dressings and place in plastic bag at the end of the bed, remove gloves and place in plastic bag, wash your hands, put on clean gloves, place soiled dressings in plastic bag, remove gloves and place in plastic bag, wash your hands, put on clean gloves,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident (R1) was not subjected to physical abuse from another resident (R5). This failure affects two residents. R1 is one of three residents reviewed for physical abuse in the sample list of three. R1 sustained a 2-centimeter occipital laceration to the top of the head with 3 staples. Findings include: R1's undated Face Sheet documents R1's diagnoses as Anxiety, Bipolar Mood Disorder, Dementia, Alzheimer's, Depression. R1's Minimum Data Set (MDS) dated [DATE], documents R1 severely cognitively impaired. R1's Hospital notes dated 7/25/23, document R1 as having a fall at the nursing home, traumatic injury of the head, and 2-centimeter occipital laceration to the top of the head with 3 staples placed. On 10/6/23 at 1:45 PM, V7 RN stated, R1 approached R5 from behind. When R5 turned around, R1 tried to hug R5, like a 'side hug'. R5 pushed R1 and R1 fell and hit the back of her head. R1 had to get staples in her head. On 10/9/23 at 11:05 AM, V10…

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 employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 41 residents residing in the facility. Findings include: On 11/14/2022 at 11:09AM, V5 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V5 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. Throughout the duration of the survey, the facility failed to safely thaw food, failed to store food at safe temperatures, failed to effectively sanitize dishes, failed to properly date and label food to prevent the potential for foodborne illness, and failed to maintain sanitary kitchen equipment. The Facility Assessment (7/2022) documents a full-time clinically qualified nutrition professional is needed to provide competent support and care for the facility's resident population every day and during emergencies. The Resident Census and Conditions of…

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

Based on observation, interview, and record review, the facility failed to safely thaw food, failed to store food at safe temperatures, failed to effectively sanitize dishes, failed to properly date and label food to prevent the potential for foodborne illness, and failed to maintain sanitary kitchen equipment. These failures have the potential to affect all 41 residents in the facility. Findings include: 1. On 11/14/2022 at 11:09AM, the kitchen pantry room reach-in-cooler interior temperature measured 59 degrees Fahrenheit by the facility thermometer located inside of the cooler and 60 degrees Fahrenheit by Illinois Department of Public Health thermometer. Two five pound chubs of raw hamburger and one six pound chub of pork sausage were located on the bottom shelf of the cooler and all three packages of raw meat were cold to the touch and partially frozen. A temperature log sheet (November 2022) was located on the door of the cooler and documented daily cooler temperatures ranging from 38-56 degrees Fahrenheit. Notably, the log sheet documented a column labeled Corrective Action…

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

Based on interview and record review the facility failed to ensure the facility's Infection Preventionist was certified. This failure has the potential to affect all 41 residents residing in the facility. Findings include: On 11/15/22 at 1:44 PM, V3 Infection Preventionist/Resident Care Coordinator stated she just started as the Infection Preventionist a couple months ago. Stated she is currently doing the Infection Preventionist training but has not completed it. The facility's Census and Condition report dated 11/14/22 signed by V1 Administrator documents there are 41 residents residing in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer the opportunity to formulate advanced directives in a timely manner to meet the resident choice and failed to accurately record resident choice for life sustaining measures in the medical record for two (R243 and R25) of two residents reviewed for advanced directives in a total sample list of 22. Findings include: 1) R243's undated face sheet documents a current admission date of 3/23/22. R243's Minimum Data Set, dated [DATE] documents R243 as cognitively intact. R243's physician order sheet dated November 2022 documents R243 as a full code. R243's Practitioner Order for Life-Sustaining Treatment Form (POLST) dated 10/28/22 documents, Do Not Attempt Resuscitation, Comfort Focused Treatment. 2) R25's undated face sheet documents an admission date of 9/22/22. R25's Minimum Data Set, dated [DATE] documents R25 as cognitively intact. R25's physician order sheet dated November 2022 documents code status as full code. R25's Practitioner Order for…

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

Based on interview and record review, the facility failed to notify R22 of discontinuation of Medicare services. This failure affects one resident (R22) of three reviewed for beneficiary notifications in the sample list of 22. Findings include: On 11/16/2022 at 1:12PM, V11 (Business Office Manager) reported the facility did not issue R22 the required notifications of discontinuation of Medicare benefits following R22's discharge from therapy services on 10/26/2022. V11 reported R22 continued to live in the facility after 10/26/2022. R22's medical record (undated) did not document R22 received the Notice of Medicare Non-Coverage and the Advanced Beneficiary Notice of Non -Coverage following R22's discharge from Medicare.

Based on interview and record review, the facility failed to obtain and document required signatures to certify the accuracy of resident Minimum Data Set (MDS) assessments. This failure affects four residents (R15, R19, R20, R21) of five reviewed for MDS assessments in the sample list of 22. Findings include: R15's Minimum Data Sets (5/10/2022, 9/16/2022) fail to document assessor signatures for all completed sections of the assessments. R19's Minimum Data Sets (7/27/2022, 9/15/2022) fail to document assessor signatures for all completed sections of the assessments. R20's Minimum Data Set (8/8/2022) fails to document assessor signatures for all completed sections of the assessment. R21's Minimum Data Set (8/4/2022) fails to document assessor signatures for all completed sections of the assessment. On 11/16/2022 at 3:30PM, V1 (Administrator) reported the facility currently does not have a resident assessment coordinator working permanently in the facility, but only a person who travels between facilities. V1 reported the facility MDS assessments very well may have been late.

Based on interview and record review the facility failed to justify the use of psychotropic medications by failing to track behaviors and complete assessments for the use of psychotropic medications in three (R13, R16 and R26) of five residents reviewed for psychotropic medication administration from total sample list of 22. Findings include: 1) R13's physician's order sheet dated April 2022 documents Risperidone (antipsychotic) 0.5 milligrams and Risperidone 0.25 milligrams to be given before bed, by mouth, with an order date of 7/26/21. The medical record did not contain an initial assessment or quarterly assessments for Risperidone use from 7/26/21 until 11/8/22. 2) R16s physician order sheet dated July 2022 documents Ziprasidone Hydrochloride (antipsychotic), 20 milligrams to be taken every other day by mouth with an order date of February 20, 2021. The medical record did not contain an initial assessment for Ziprasidone Hydrochloride for R16. The medical record did not contain quarterly assessments from February 20, 2021 until June 5, 2022. On 11/17/22 at 12:00PM, V2 Director…

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.