Charleston Rehab and Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the rights of the residents to be free from verbal/emotional abuse from staff and other residents. This failure affected seven of eight residents (R2, R4, R5, R6, R7, R9, R13) reviewed for abuse on the sample list of 17. Findings Include: 1. R2's Medical Diagnosis List dated August 2025 documents R2 is diagnosed with Epilepsy. R2's Care Plan dated 7/26/25 documents R2 has a diagnosis of Seizure Disorder. Staff are to administer medications, protect from onlookers, provide post seizure treatment, and take vital signs and do neuro checks post seizure. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact. On 8/29/25 at 12:15 PM, R2 stated V13 Licensed Practical Nurse (LPN) often tells others that he is faking his seizures. R2 stated this makes him feel upset and mad. R2 stated he (R2) does not fake his seizures, and it is embarrassing that the nurse doesn't believe that he (R2) is dealing with seizures. R2 stated he believes V13…

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 on two separate occasions affecting one (R8) resident from staff interactions to the State Agency timely out of three residents reviewed for Abuse in a sample list of 17 residents. Findings include:R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. R8's Nurse Progress Note dated 8/17/2025 at 12:24 PM documents R8 was crying, stating staff was not listening, laughing at her and states she wanted to leave Against Medical Advice (AMA). On 8/26/25 at 12:10 PM, V1 Administrator was informed of an allegation of mental abuse of R8 from staff V2 Director of Nursing (DON), V14 Licensed Practical Nurse (LPN) and V20 LPN on 8/13/25. V1 stated this allegation was never reported to the State Agency. On 8/27/25 at 1:40 PM, V1 Administrator stated she was not made aware of R8's allegation of mental abuse from staff on 8/13/25 nor 8/17/25. V1 stated she was made aware through her own record review of R8 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to effectively supervise an unalarmed and unlocked facility exit door. This failure resulted in R3, a resident with a diagnosis of Dementia, eloping unnoticed from the facility and exiting through the facility courtyard towards the facility parking lot area. The facility also failed to identify and document any root-cause for R3's elopement in their elopement investigation. R3 is one of three residents reviewed for supervision in the sample of 17. Findings include: R3's Medical Diagnosis sheet (8/27/2025) documents R3's diagnoses including Dementia, Weakness, Muscle Wasting and Atrophy, and Unsteadiness on Feet. R3's Orders sheet (8/27/2025) documents the order May be up ad-lib (at liberty) per plan of care. R3's Elopement Assessment (6/4/2025) documents R3 is cognitively impaired, independently mobile, and has the elopement risk factor of a recent mental status change. R3's Resident Assessment (6/10/2025) documents R3 has severe cognitive…

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 document a resident (R3) elopement and subsequent investigation in the resident's medical record. This failure affects one resident (R3) of three reviewed for elopement in the sample of 17.Findings include:R3's Medical Diagnosis sheet (8/27/2025) documents R3's diagnoses including Dementia, Weakness, Muscle Wasting and Atrophy, and Unsteadiness on Feet. R3's Orders sheet (8/27/2025) documents the order May be up ad-lib (at liberty) per plan of care. R3's Elopement Assessment (6/4/2025) documents R3 is cognitively impaired, independently mobile, and has the elopement risk factor of a recent mental status change.R3's Resident Assessment (6/10/2025) documents R3 has severe cognitive impairment.R3's Care Plan (8/27/2025) documents R3 only requires a minimal level of staff assistance as needed for ambulation.The facility incident report (8/8/2025) documents V5 (Certified Nursing Assistant) noticed R3 walking on a sidewalk outside of the facility on 8/2/2025…

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) for one (R8) resident on Enhanced Barrier Precautions (EBP) out of three residents reviewed for Urinary Tract Infections (UTI) in a sample list of 17 residents. Findings include:R8's Minimum Data Set (MDS) dated [DATE] documents R8 as cognitively intact. This same MDS documents R8 as requiring maximum assistance for toileting and moderate assistance for dressing, personal hygiene and bathing.R8's Electronic Medical Record (EMR) documents R8 is on Enhanced Barrier Precautions (EBP) due to R8 having a history of a Multi Drug Resistant Organism (MDRO) and currently has an indwelling urinary catheter. On 8/27/25 at 2:00 PM, V15 and V16 Certified Nurse Assistants (CNA) provided indwelling urinary catheter care and perineal care for R8. R8 had a sign on the wall outside her door next to the floor that read 'Enhanced Barrier Precautions' (EBP). V15 and V16 did not wear gowns when providing direct…

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 check their medical equipment on a timely basis to ensure the medical equipment is in good working condition. The failure of maintaining the Automated External Defibrillator (AED) prevented the use of the AED during an episode of Cardiac Failure for one resident (R1) reviewed for Cardiac Failure in a sample of one. Findings include:Progress notes for R1 dated [DATE] at 7:01 PM document R1's return from the hospital to the facility with the diagnosis of Acute Respiratory Failure with Hypoxia. On [DATE] staff was sent to get V25 Registered Nurse (RN) due to R1 having an episode of not breathing and unresponsive. V25 asked staff to take R1 to his room and place him on the bed with the cardiac board behind R1's back and to obtain the cardiac cart due to R1's medical status. On [DATE] at 9:56 AM, return call from V25 RN (Registered Nurse) was received and V25 stated R1 's head was bent over and R1 still had a weak pulse and was breathing slowly. V25 asked…

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

Based on record review and interview the facility failed to maintain a professional standard of conduct, by working under the influence of alcohol. This failure had the potential to affect all 54 residents that reside in the facility. Findings include: V5, Previous Administrator EMPLOYEE CORRECTIVE ACTION FORM documents the date of offense occurred 02/18/25. The same form documents: Offense: Category I (Gross Misconduct - Immediate Discharge) Failure to follow appropriate policies or procedures that results in harm/potential harm to a team member, resident, or visitor. The same form documents: On 2/20/25, admitted to consuming alcoholic beverages on 2/18/2025, a few hours before entering the community (facility), conducting a brief round. allowing 2 (two) clinical team members, who also consumed alcohol, to conduct skills checks with staff and assist with opening a Stat Safe for a medication. V3, Assistant Director of Nursing (ADON) EMPLOYEE CORRECTIVE ACTION FORM documents the date of offense occurred 02/18/25. The same form documents: Offense: Category II (Misconduct) Third…

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 a resident's right to privacy by posting a video of R1 in the facility, on social media. The facility also failed to protect a resident's right to privacy during wound care for R10. This failure affects two of five residents (R1 and R10) reviewed for privacy on the sample list on 17. Findings include: 1.) R1's most recent Diagnoses Sheet documents the following: Other, Alzheimer's Disease, Cognitive Communication Deficit, Parkinson's Disease Without Dyskinesia, and Generalized Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents the following: R1 had severe cognitive impairment, uses a wheelchair, and is dependent on staff for mobility. On 4/3/25 at 4:55 pm V3, Assistant Director of Nursing (ADON) stated (V12, Licensed Practical Nurse/LPN) alerted me that there was a video on social media of (R1). (V12, LPN had it on her phone. It was of two Agency CNA's (Certified Nursing Assistants), (V6, CNA) and (V7, CNA) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to protect the resident's right to be free from mental abuse of (R1) by V6 and V7, Agency Certified Nursing Assistants (CNA's). This failure affected one of four residents (R1) reviewed for abuse on the sample list of 17. Findings include: R1's most recent Diagnoses Sheet documents the following: Other, Alzheimer's Disease, Cognitive Communication Deficit, Parkinson's Disease Without Dyskinesia, and Generalized Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents the following: R1 had severe cognitive impairment, uses a wheelchair, and is dependent on staff for mobility. The facility email to Illinois Department of Public Health Final Report dated [DATE] documents: It was reported to leadership on [DATE] at 1:35 pm, a video was on social media showing inappropriate engagement with a resident, with 2 (two) agency CNA's (V7 and V8, Certified Nursing Assistants) from (Nurse Staffing Agency). The CNA's involved from (Nurse…

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 correctly identify a resident prior to administering medications resulting in a resident receiving another resident's medications. This failure affects one of 12 residents reviewed for medication administration in the sample list of 14. Findings include: The Physician Order Sheet dated October 2024 documents R1's primary diagnoses as Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Acute Respiratory Failure with Hypoxia, and Sepsis and R1's Hospice diagnoses as Chronic Ischemic Heart Disease, Heart Failure, and Unspecified Atrial Fibrillation. R1's BIMS (Brief Interview for Mental Status) for R1's annual assessment in October 2024 documents R1 as severely impaired with decision making skills. R1's MDS (Minimum Data Set) dated October 2024 documents R1 requires a mechanical lift for transfers to his special design wheelchair and R1 requires all activities of daily living to be completed by staff to including feeding. On 10/29/24 at 8:15 AM, the facility report titled MED ERROR was completed by…

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 required personnel attended the quarterly Quality Assessment and Assurance (QAA) committee meetings and failed to hold (QAA) committee meetings quarterly. This failure has the potential to affect all 60 residents residing in the facility. Findings Include: The facility QA (Quality Assessment & Assurance) Meeting Members list documents the required facility leadership and staff except there is no required Infection Preventionist on the QA member list. The facility QAPI (Quality Assurance Performance Improvement) Policy plan updated January 2024 documents the following: The QAPI Program takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality while involving all caregivers in practical and creative problem solving. The community QAPI Program achieves the following: monitor quality/performance, find opportunities for improvement, improve performance, achieve resident/family desired outcomes, meet regulatory requirements, understand the CMS survey process 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 have an operational Legionella water management plan. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The facility's Legionella Management Procedure documents that this procedure policy was last reviewed on 8/10/2018. This policy did not contain an assessment to identify areas where Legionella and other pathogens could grow and spread, or measures to prevent and monitor the growth of water borne pathogens. On 9/05/24 at 12:05 PM, V24 (Maintenance Director) stated he has been the facility's Maintenance Director for about four years. V24 stated V24 has not done anything with the Legionella water management plan since he started. V24 stated, Corporate has never talked to me about that. V24 stated he has never assessed the building for areas where Legionella or other pathogens could grow. V24 stated he does not have a routine to flush water lines that are not in use. On 9/05/24 at 12:08 PM, V14 (Regional Infection Preventionist) states V24 is responsible for implementing 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 ensure the Infection Preventionist completed specialized training in infection prevention. This failure has the potential to affect all 60 residents in the facility. Findings Include: The facility's Infection Control Manual dated 2019 documents, the facility will designate an Infection Preventionist, the Infection Preventionist will have completed specialized training in infection prevention and control. On 9/04/24 at 11:06 AM, V2 (Director of Nursing) states V14 (Regional Infection Preventionist) is acting as the facility Infection Preventionist until a facility nurse is trained to take over the role and is educated. On 9/04/24 at 2:16 PM, V14 stated she is the facility's Infection Preventionist, and she does not currently have a copy of her training certificate and she will try and bring it tomorrow. On 9/06/24 at 8:30 AM, V8 (Wound Nurse) stated V14 couldn't find her certificate but would be in the facility later today. On 9/06/24 at 11:00 AM, V3 (Assistant Director of Nursing) states that V14 would not be in 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 record review and interview, the facility failed to ensure staff were provided the required abuse prevention education. This has the potential to affect all 60 residents in the facility. Findings include: On 9/6/24 at 11:24 V1, Administrator /Abuse Prevention Coordinator confirmed the facility has no facility-wide documentation of staff education on abuse training to provide this surveyor. V1 stated the current new company providing management of the facility does not have access to the previous owner of the facilities education documents. The facility policy ABUSE, PREVENTION AND PROHIBITION POLICY dated as revised January 2024, documents the following: The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response: The facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. If the Administrator is not available 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 ensure that call lights were in reach for four (R28, R32, R6, and R29) of 24 residents reviewed in a sample list of 39. Findings Include: The facility's Certified Nursing Assistant's Guidebook dated 2021 documents to ensure the call light is in reach before leaving the room. 1.) On 9/03/2024 at 9:52 AM, R28 was laying in the bed. R28's call light was not in R28's reach. The call light cord was laying on the floor at the foot of R28's bed. R28's care plan dated 3/13/2023, documents R28 is a high risk for falls. This care plan includes an intervention to ensure that the call light is within reach and to encourage R28 to use it as needed for assistance. 2.) On 9/03/2024 at 10:03 AM, R32 was laying in bed. R32's call light was not in R32's reach. A bedside table was positioned up against R32's head of the bed. R32's call light was laying on the floor on the side of the bedside table furthest from the bed. On 9/06/2024 at 8:55 AM, R32 was sitting up in a wheelchair in R32's room. R32's call light was not in R32'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.

Based on observation, interview and record review, the facility failed to provide dependent residents timely assistance to eat. This failure affected seven out of seven residents (R1, R3, R29, R34, R37, R40, and R51) reviewed for dining assistance on the sample list of 39. Findings include: The facility Resident Council Meeting Minutes dated 5/03/24 documents: No CNA (Certified Nursing Assistance) at the (resident assistance) table at night (evening meal). Playing on their phones. R1, R3, R29, R34, R37, R40, and R51's current care plan document they each require physical staff assistance with dining. On 9/3/24 at 12:04 pm - 12:45 pm during dining observation, there was an approximately nine-foot, designated dining room table for resident's dependent on physical staff assistance to consume their meal. The designated table had seven residents (R1, R3, R29, R34, R37, R40, and R51) present and waiting to be assisted with dining. All seven resident meals had already been served by 12:04 pm. Each of the seven residents' food plate had the plate cover removed, and the food left open to…

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

Based on interview and record review, the facility failed to hold administration of a resident's blood pressure medication per medical provider's orders. This failure resulted in R14 receiving unordered medication for an additional 23 days. This failure affects one resident (R14) of five reviewed for unnecessary medications in the sample list of 39. Findings include: R14's diagnosis list (9/4/2024) documents the diagnosis of hypertension (high blood pressure). R14's Physician Orders (printed 9/4/2024) documents R14 was ordered the medication spironolactone, 50 milligrams by mouth, once daily, beginning on 6/10/2024. On 9/3/2024 at 12:00 PM, R14 reported taking the medication spironolactone (a diuretic primarily used to treat high blood pressure) and then having low blood pressure and feeling dizzy from the medication. R14 reported also taking other blood pressure medications and recently refusing additional doses of the spironolactone after experiencing the symptoms of low blood pressure and dizziness. V5 (R14's medical provider) documented (progress notes 8/6/2024) R14 complained…

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 residents' right to be free from physical abuse by another resident. This failure affected two of two residents (R44, R58) reviewed for abuse on the sample list of 39. Findings include: R58's Resident to Resident Physical Aggression Initiated form dated 8/28/24 at 03:36 am documents the following: (R58) grabbed the other resident's (R44) arm. The other resident (R44) swung empty coffee cup at other resident (R58) without making contact. Second resident (R44) received a small laceration on his rt. (right) forearm. The same form documents: Predisposing Situation Factors (box checked) Wanderer. The same form documents: Resident (R58) has Schizophrenia, Dementia with Psychosis. R58's Minimum Data Set (MDS) dated [DATE] documents R58's Brief Interview of Mental Status score of 11 of a possible 15, indicating moderate cognitive impairment. R58's same MDS documents: Indicators of Psychosis: Yes (box checked) Delusions. The same MDS…

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

Based on interview and record review the facility failed to complete a thorough physical abuse investigation related to a resident-to-resident altercation. This failure affects two of two residents (R44, R58) reviewed for abuse on the sample list of 39. Findings include: The facility Alleged Physical Abuse Final report of R44 by R58 documents on 8/28/24 around 0200 the resident (R58) had an altercation with resident (R44). Per witness statements from staff and report from (R44), (R58) was unprovoked and went to (R44) who was in his wheelchair by the nurse's station heading to get coffee and (R58) grabbed (R44) (R44) right arm causing a laceration. R2 (R44) yelled and the CNA (unidentified) that was behind the nurse's station immediately got up and went to address the situation and yelled for another CNA (unidentified) to help separate the residents quickly. As CNA was approaching (R58) and (R44), (R44) began to swing his cup at (R58) in defense. There is no conclusion documented in the investigation that the facility acknowledged alleged abuse was or was not substantiated. On 9/4/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to request a new Level 1 PASARR within 30 days of admission for one (R32) of one resident reviewed for PASARR in a sample list of 39. Findings include: R32's Level 1 PASARR (Preadmission Screening and Resident Review) dated [DATE] documents, Your Level 1 screen shows you have evidence of serious or intellectual disability (IDD). Further PASARR is not required because you meet the criteria for an exempted hospital discharge. This means you may stay up to thirty (30) days in a Medicaid certified nursing facility without further PASARR evaluation. If you or your care provider thinks you need to stay longer than thirty (30) days, a nursing facility staff member must submit a new level 1 screen to Maximus. This must be completed by or before the 30th day after your admission to the nursing facility. There were no other PASARR screenings in R32's medical record. On [DATE] at 12:20 PM, V1 Administrator states they had not requested a new PASARR (for R32)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 interview and record review, the facility failed to identify a residents' specific behaviors necessitating anti-psychotic medication use. The facility also failed to develop, implement, and care plan non-pharmacological interventions prior to use of anti-psychotic medication. These failures affect one resident (R20) of five reviewed for unnecessary medications in the sample list of 39. Findings include: R20's Physician Orders (printed 9/5/2024) document the following anti-psychotic medication order: Risperidone (anti-psychotic medication), give a 0.25 milligram tablet orally once daily for Major Depressive Disorder with a prescription start date of 3/4/2024. R20's Care Plan (printed 9/5/2024) does not document any specific targeted behaviors, expressions of psychic distress, or non-pharmacological interventions in lieu of anti-psychotic medication use for R20. R20's quarterly assessment (1/6/2024) documents R20 does not have indicators of psychosis and does not have behaviors. On 9/5/2024 at 10:55AM, V8 denied R20 has indicators of persistent psychic distress or persistent…

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 apply treatments as ordered by the physician and care plan interventions for two (R34 and R12) of two residents reviewed for skin condition in a sample list of 39. Findings include: 1.) On 09/03/2024 at 10:53 AM, R34 was sitting in a geriatric chair in the day room. There was a six inch long scabbed area to R34's face on the right cheek. R34 had multiple small scabbed areas to R34's arms, chest, and face. There was scattered red flaky patches on R34's skin. There was blood present under R34's fingernails. On 09/03/2024 at 12:16 PM, V21 (R34's family member) stated R34 has a history of Eczema and frequently itches and picks at R34's skin. R34's physician order dated 7/09/2024 document an order for Tacrolimus cream (topical ointment used for Eczema) twice a day for 14 days and then as needed after the 14 days. R34's medical record also includes a physician order dated 2/16/2024 to apply Calamine External lotion twice a day as needed for itching. R34's Medication and Treatment Administration Records dated July,…

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 catheter care in a manner that prevented cross contamination, ensure urinary collection bags were placed up off the floor, secure a residents catheter tubing, and failed to develop a catheter care plan for residents. This failure affects three (R28, R6, R29) of three residents reviewed for catheters on the sample list of 39. Findings include: 1.) On 9/4/24 at 11:22 am Certified Nurse Assistants (CNA) V10 and V11 performed catheter care on R29. R29's Physician's Order Sheet (POS) dated September 2024 documents the following for R29: Obstructive and Reflux Uropathy, Unspecified and Retention of Urine, Unspecified. The same POS has an order for R29 to have an 18 French foley catheter with a 30cc balloon which is ordered to be changed every 30 days. R29 also has a meatal tear at the tip of his penis. V10, was the CNA performing catheter care and V10 used no rinse wipes on R29. V10 cleaned around the end of the penis with a wipe and did not change the area of the wipe and proceeded to wipe down R29's shaft…

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

Based on interview and record review, the facility failed to prevent unnecessary use of anti-psychotic medication (Risperidone) by failing to identify and document an approved diagnosis for anti-psychotic use and failing to identify and track targeted behaviors or persistent psychiatric distress necessitating the use of anti-psychotic medication. These failures affect one resident (R20) of five reviewed for unnecessary medications in the sample list of 39. Findings include: R20's Order Summary Report (printed 9/5/2024) documents R20's diagnosis list including diagnoses of Major Depressive Disorder and Anxiety Disorder. No other psychiatric diagnoses are present on the Report. The same record does not document any diagnosis approved for use of anti-psychotic medication. R20's Physician Orders (printed 9/5/2024) document the following anti-psychotic medication order: Risperidone (anti-psychotic medication), give a 0.25 milligram tablet orally once daily for Major Depressive Disorder with a prescription start date of 3/4/2024. On 9/5/2024 at 10:55AM, V3 (Assistant Director of Nursing)…

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 honor food preferences for one of seven residents (R34) reviewed for food preferences on the sample list of 39. Findings include: R34's Minimum Data Set, dated [DATE] documents R34's Brief Interview of Mental Status score as three out of a possible 15, indicating severe cognitive impairment. R34's current Physician Order Summary Sheet documents R34's diet order as Regular diet, Mechanical Soft texture, Honey/Moderately Thick consistency (liquids). R34's undated Lunch Meal Ticket undated, documents R34 dislikes all vegetables. On 9/5/24 at 12:20 pm, V7, Certified Nursing Assistant (CNA) was feeding several residents (unidentified) at the resident assisted dining room table. R34's plate of mechanical soft meat, mashed potatoes and whole cooked cauliflower was untouched. V7 stated R34 did not like what was served, and V7, CNA had ordered R34 a grilled cheese. V7, CNA confirmed R34's diet card documents R34 does not like any vegetables. V7,…

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 offer influenza vaccinations for one (R6) of five residents reviewed for immunizations on a sample list of 39. Findings include: The facility's Infection Prevention and Control Manual dated 09/2022 documents it is the policy of this facility that all residents will be offered influenza vaccinations. R6's immunization report documents R6 routinely received the influenza vaccination. This report documents that R6 received the influenza vaccine in 2010, 2012, 2013, 2014, 2015, 2016, 2017, 2018, 2019, 2020, and 2021. This report does not document that R6 received the influenza in 2022 or 2023. R6's medical record does not document that R6 was offered the influenza vaccination in 2022 or 2023. On 9/06/24 at 8:26 AM, V8 (Registered Nurse) states that they have no records for R6's influenza vaccine.

Based on interview and record review the facility failed to offer a vaccination booster for Covid-19 for one (R36) of five residents reviewed for immunizations in a sample list of 39. Findings Include: On 9/03/24 at 10:40 AM R36 states he has not been offered any vaccinations since admitted to the facility. R36 states he would like to receive the Covid-19 booster immunization. R36's immunization record documents R36 has not received a Covid-19 vaccination since 4/01/21. On 9/06/24 at 8:26 AM, V8 (Registered Nurse) stated the facility had a Covid-19 vaccination clinic from an outside organization in June of 2024. V8 stated R36 should have been offered a Covid-19 vaccine during the vaccination clinic, but his name was not placed on the list for the clinic. V8 stated R36 should have been on this list to receive the Covid-19 vaccination.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the physician of a new diabetic foot ulcer, obtain a treatment order, and complete wound assessments for multiple days after the wound was found for one of three residents (R1) reviewed for diabetic ulcers in a sample list of six. Findings include: The Physician's Order Sheet (POS) dated June 2024 lists the following diagnoses for R1: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure. The Minimum Data Set (MDS) assessment dated [DATE] documents R1's mental status is moderately cognitively impaired. The same MDS documents R1 needs staff assistance for all activities of daily living to include showers. R1's 5/21/24 shower sheet states R1's right great toe has a black sore. V5 CNA (Certified Nurse Assistant) reported this information to the Charge Nurse V6, RN (Registered Nurse). R1's progress note dated 5/21/24 at 10:16 AM states Skin/Wound Note: R1 has open area to right toe and area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the Physician and the Power of Attorney when changes were identified for R1 relating to diabetic ulcers of R1's right great toe. R1 is one of three residents reviewed for diabetic ulcers in a sample list of six residents. Findings include: The Physician's Order Sheet (POS) dated June 2024 lists the following diagnoses for R1: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Chronic Diastolic (Congestive) Heart Failure. The Minimum Data Set (MDS) assessment dated [DATE] documents R1's mental status is moderate cognitively impaired. The same MDS documents R1 needs staff assistance for all activities of daily living and R1's showers are given to him twice a week by staff. On 5/21/24 R1's shower sheet stated R1's right great toe has a black sore. V5 CNA (Certified Nurse Assistant) reported this information to the Charge Nurse V6, RN (Registered Nurse). R1's progress note dated 5/21/24 at 10:16 AM states Skin/Wound Note: R1 has open…

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 (R2) right to be free from physical abuse by another resident (R1). R1 and R2 are two of three residents reviewed for abuse in the sample of three. Findings include: R2's Diagnosis Sheet (current) includes the following diagnoses: Unspecified Fall, Fracture of the Mandible, Non-Displaced Fracture of Cervical Vertebrae two, Dementia and Anxiety. A facility report titled Final Report dated 2/23/24 documents the following summary: On 2/18/2024, while residents were awaiting breakfast in the facility dining room, resident (R1) grabbed another resident's (R2) shirt sleeve and pulled (R2) to the ground during a behavioral episode. Staff present in and near the dining room immediately intervened and separated (R1 and R2). (R1 and R2) were immediately assessed by unit Nurse (V4 Registered Nurse) and all necessary parties notified. (R2) was sent to (Hospital Emergency Department) for evaluation related to prescribed. (R2)…

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

Based on interview and record review, the facility failed to report an injury of unknown origin/source for one (R1) of three residents reviewed for abuse in the sample of three. Findings include: R1's Diagnosis Sheet (current) includes the following diagnoses: Violent Behavior, Bipolar Disorder, Depression, Autistic Disorder and Cerebral Vascular Accident. R1's Admitting Diagnosis from the Hospital dated 12/22/23 also includes the diagnosis of Violent Behavior. R1's Progress Notes dated 1/24/24 document that Therapy reported R1's right hand as swollen and bruised. Administrator and IDT (interdisciplinary team) informed, investigation initiated. On 2/29/24 at 10:15 am, V2 Director of Nursing and V1 Administrator, confirmed that R1's injury had not been reported to the State Agency. V2 stated when I went to look at (R1's) hand I thought the injury was caused by (R1) dangling the hand between the wall and the wheelchair and hitting it on the wall. The bruise appeared to match the shape of the brake. V2 confirmed V2 did not know for sure that is what happened. No incident report for 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 complete and document a thorough investigation into a resident's (R1) hand injury of unknown source. R1 is one of three residents reviewed for abuse in the sample of three. Findings include: A Progress Note dated 1/24/24 documents Physical Therapy Services reporting that R1's hand is swollen and bruised. This same note documents that Administration was notified of R1's hand injury. R1's Physician Order Sheet, Care Plan and Diagnosis Sheet (current) all document R1 with Violent Behavior and Aggression. On 2/29/24 at 10:15 am, V1 Administrator stated the facility did not have a documented investigation concerning R1's hand injury. On 2/29/24 at 10:15 am, V2 Director of Nursing stated V2 looked at R1's hand and because R1 is often seen dangling the hand while using R1's wheelchair and the hand being between the wall and wheelchair she thought the bruise and swelling came from this. V2 stated the bruise appeared to be matching up to the wheelchair brake. V2 also confirmed that V2 did not know for sure this is how the injury…

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 supervise a resident (R1) with known aggression and other inappropriate behaviors towards others while in the facility dining room. This failure resulted in R1 pulling another resident (R2) and the resident's (R2) wheelchair onto the floor. Findings include: R1's Diagnosis Sheet (current) includes the following diagnoses: Violent Behavior, Bipolar Disorder, Depression, Autistic Disorder and Cerebral Vascular Accident. R1's Admitting Diagnosis from the Hospital dated 12/22/23 also includes the diagnosis of Violent Behavior. R1's Progress Notes dated 2/18/24 document an occurrence in the dining room at breakfast with R1 pulling another resident (R2) and R2's wheelchair to the ground. On 2/29/24 at 11:05 am, V4 Registered Nurse confirmed that R1 was in the dining room at breakfast. V4 stated V4 had V4's medication cart outside the dining room behind the wall that divides the lounge from the dining area. V4 stated V4 could not see the residents in the dining room at the time the above occurrence happened with R1 and R2. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to document three compartment sink temperatures and sanitizer levels, failed to properly store and label perishable foods, and failed to maintain a sanitary kitchen environment. These failures have the potential to affect all 64 residents residing in facility. Findings include: The daily midnight census report dated 11/19/23 documents 64 residents residing in facility. 1.) The facility policy titled 'Refrigerator and Freezer Storage' revised 10/14 documents any item to be placed in the refrigerators and freezers must be covered, labeled and dated with a date-marking system that tracks when to discard perishable foods. On 11/19/23 at 8:35 AM the facility kitchen was toured with the following observations: --The reach in cooler contained a clear bag of unlabeled, sliced white deli meat (turkey) with handwritten dates '11/12/23-11/18/23' written in black marker on the bag. --The upright freezer contained a large clear bag of unlabeled, undated,…

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

Based on observation, interview, and record review the facility failed to ensure oxygen tubing was kept off of the floor, failed to clean and store bilevel positive airway pressure (BIPAP) and continuous positive airway pressure (CPAP) machines/tubing/masks in a sanitary manner, failed to change and label oxygen tubing weekly and failed to administer the accurate amount of oxygen for seven of seven residents (R5, R13, R19, R31, R1, R28, R57) reviewed for respiratory care on the sample list of 39. Findings include: The facility's Oxygen Therapy policy dated March 2019 documents oxygen should be administered with a written physician order. Oxygen tubing/mask/cannula should be changed on a weekly basis, dated, and documented as changed on the treatment administration sheet (TAR). The facility's CPAP/BIPAP policy dated March 2013 documents CPAP and BIPAP machine circuits and filters will be cleaned weekly. 1. R5's undated Medical Diagnoses list documents R5 is diagnosed with Dementia, Congestive Heart Failure, and Diabetes. R5's Physician Order Set (POS) documents an order for oxygen 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 interview and record review the facility failed to complete psychotropic medication assessments, identify and monitor/track targeted behavioral interventions and nonpharmacological interventions, document clinical rational and orders to continue PRN (as needed) antianxiety medication, complete AIMS (Abnormal Involuntary Movement Scale) assessments, and follow up on pharmacy recommendations to attempt gradual dose reductions of psychotropic medications for five (R9, R21, R4, R54, R31) of five residents reviewed for unnecessary medications in the sample list of 39. Findings include: The Psychotropic Medication Policy revised 11/28/17 documents: It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: 1. In an excessive dose, including duplicative therapy 2. For excessive duration 3. Without adequate monitoring 4. Without adequate indications for use. 5. In the presence of adverse consequences that indicate the drugs should be reduced or…

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

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 (R25) resident out of one resident reviewed for Dignity in a sample list of 39 residents. Findings include: R25's undated Face Sheet documents medical diagnoses of Dementia, Age Related Physical Ability, Muscle Weakness, Chronic Congestive Heart Failure and Atrial Fibrillation. R25's Minimum Data Set (MDS) dated [DATE] documents R25 as severely cognitively impaired. This same MDS documents R25 requires assistance with personal hygiene and bathing. R25's Care Plan intervention dated 2/21/23 documents R25 is dependent on staff for personal hygiene and oral care. On 11/19/23 09:45 AM R25 was sitting in the wheelchair in his room. R25's chin had a half dollar sized dark brown area. R25's facial hair was brown in the same area with the rest of R25's facial hair being white. R25 rubbed at chin area and was not able to rub off the brown spot. On 11/19/23 at 12:30 PM R25 was sitting at the dining room table surrounded by…

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 a physician order to keep medications at bedside, identify which medications were safe to keep at bedside, and develop a plan of care for self-administration of medications for one of one residents (R57) reviewed for self-administration on the sample list of 39. Findings include: 1. On 11/19/23 at 8:27 AM, three inhalers (Ventolin, Combivent, and Symbicort), two nasal sprays (Azelastine and Fluticasone), and one unlabeled syringe of medication was sitting on top of R57's bedside table. R57 was sitting in a chair next to the table and stated those are for my breathing and my mouth sores. R57's Medication Administration Record (MAR) documents physician orders dated 6/27/23 for Azelastine HCl Nasal Solution 0.1 %, 2 sprays in both nostrils two times a day for allergies, Fluticasone Propionate Nasal Suspension 50 MCG/ACT (microgram/actuation) 2 spray in both nostrils two times a day for allergies, Ventolin HFA Inhalation Aerosol Solution…

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 Advance Beneficiary Notices to two of three residents (R54, R57) reviewed for reviewed for Beneficiary Protection Notifications on the sample list of 39. Findings include: 1.) R54's Beneficiary Protection Notification Review documents R54's last covered Medicare day is 8/9/23, the facility/provider initiated the discharge, and R54's Medicare Part A days were not exhausted. This form documents R54 was not given an Advanced Beneficiary Notice of Non-Coverage (ABN). The explanation documented is R54 met R54's maximum potential and a recommendation that R54 continues to reside in the facility for 24-hour supervision. 2.) R57's Beneficiary Protection Notification Review documents R57's last covered Medicare day is 8/31/23, and R57 was not given an ABN. This form documents the reason as R57 met maximum potential and chose to remain in the facility. On 11/20/23 at 10:35 AM V10 Social Services Director stated V10 provides residents the NOMNC (Notice of Medicare Non-Coverage) form when residents have met their maximum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a clean, orderly, homelike environment for two of three residents (R8, R19) reviewed for Environment on the sample list of 39. Findings include: 1. R8's undated Medical Diagnoses List documents R8 is diagnosed with Schizoaffective Disorder, Dementia, Alzheimer's Disease, Epilepsy, Severe Intellectual Disability, Violent Behavior, and Anxiety Disorder. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. On 11/19/23 at 10:07 AM R8 was seated in a reclining chair in his room. R8's room appeared very dirty with dirt and spots of blood on the floor, no bed linens on his bed, a dirty and stained mattress, dirty fall mat in the corner of the room, food debris and crust dried all over his recliner, a broken chair sitting next to his recliner, and a dirty and stained wheelchair seat cushion. 2. R19's undated Medical Diagnoses List documents R19 is diagnosed with Intellectual Disabilities, Schizophrenia,…

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 attempt to reduce the use/form of a physical restraint for one (R6) out of one resident reviewed for restraints in a sample list of 39 residents. Findings include: R6's Medical Record documents medical diagnoses of Cerebral Palsy, Scoliosis, Personal History of Non-Suicidal Self Harm, Epilepsy, Hemiplegia Affecting Right Dominant Side, Dysphagia, Profound Intellectual Disabilities and Dependence on Wheelchair. R6's Physician Order Sheet (POS) dated November 2023 documents a physician order starting 1/24/23 to attach seat belt to special wheelchair when up in wheelchair due to spastic movement secondary to Cerebral Palsy (CP). Release every two hours and as needed. R6's Care Plan documents R6 utilizes a specialized wheelchair with a halter belt attached to wheelchair. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is severely cognitively impaired. This same MDS documents R6 requires total dependence on two people with total body…

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

Based on interview and record review the facility failed to timely report an allegation of staff to resident abuse to the administrator and to the state survey agency for one of one residents (R21) reviewed for abuse in the sample list of 39. Findings include: The facility's Abuse Prevention Program dated February 2019 documents employees are to immediately report allegations of abuse/mistreatment to a supervisor and to the administrator. This policy documents a written report of the allegation will be submitted to the Illinois Department of Public Health (IDPH). This policy documents to report reasonable suspicions of crime that result in serious bodily injury or sexual abuse within two hours after forming the suspicion, otherwise the report must be made within 24 hours. This policy does not include reporting to IDPH within two hours of the allegation. R21's Social Service Note dated 8/2/2023 at 9:00 AM documents the following: A dayshift Certified Nursing Assistant (V17 CNA) reported that R21 told V17 that a 3rd shift staff member took R21's call light away, turned off R21'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.

Based on interview and record review the facility failed to thoroughly investigate and thoroughly document an abuse allegation for one (R21) of one resident reviewed for abuse in the sample list of 39. Findings include: The facility's Abuse Prevention Program dated February 2019 documents the investigator will obtain a copy of any documentation relative to the incident and follow the Resident Protective Investigative Procedures. This policy documents the final report will include the original allegation including the date, time, location, the specific allegation, by whom, and witnesses; facts determined during the investigation including a review of the resident's medical record and interviews with witnesses. A summary of all interviews conducted, including names, should be attached to the final investigation report. This policy documents the investigative procedures include reviewing written reports, interviewing the person who reported the incident, interviewing staff who had contact with the resident during the time of the alleged incident, and interviewing other residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop a care plan for smoking, anticoagulants and the use of psychotropic medications for three (R57, R21, and R9) of 24 residents reviewed for care plans on the sample list of 39. Findings include: The facility's Comprehensive Care Plan policy with a revision date of 11/1/17 documents the components of the Comprehensive care plan will include, e. Care Plan - plan of care describing a need/problem, and indicating approaches/interventions to be instituted to assist the Resident in maintaining/receiving care in relation to the need/problem. This policy also documents that the Comprehensive Care Plan shall strive to describe the resident's medical, nursing, physical, mental, and psychosocial needs and preferences. 1. On 11/19/23 at 8:25 AM, R57 had a pack of cigarettes and a lighter on a bedside table. R57 stated R57 smokes cigarettes and is allowed to keep them in the room. R57's care plan with a revision date of 10/13/23 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.

Based on interview and record review the facility failed to ensure a resident's record identified the hospice company, included active hospice orders, and included hospice in the care plan for one (R1) of one residents reviewed for hospice in the sample list of 39. Findings include: R1's Active November 2023 Physician Orders do not include orders for hospice or identify the hospice company. R1's electronic medical record did not contain a care plan. R1's care plan dated as reviewed 5/17/23, provided by V2 Director of Nursing, documents R1 has a signed Do Not Resuscitate Order and as of February 2023 R1 receives hospice/end of life care. This care plan does not identify which hospice company and contact information, hospice admitting diagnoses, or coordination of hospice services for symptom management. On 11/19/23 at 9:43 AM V5 Registered Nurse stated R1 is on hospice care and receives hospice visits two to three times per week. V5 stated V5 thinks R1 is on hospice for cardiac diagnoses. On 11/20/23 at 11:35 AM V9 Licensed Practical Nurse stated V9 usually puts the hospice form…

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 residents received foot care including toenail care for one of one resident (R8) reviewed for Foot Care on the sample list of 39. Findings include: The facility's undated Nail Care policy documents staff will keep residents' nails clean and trimmed. R8's undated Medical Diagnoses List documents R8 is diagnosed with Schizoaffective Disorder, Dementia, Alzheimer's Disease, Epilepsy, Severe Intellectual Disability, Violent Behavior, and Anxiety Disorder. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. On 11/19/23 at 10:07 AM R8 was sitting in his recliner with bare feet. R8's feet were dry and scaly and his toenails were extremely long and dirty. On 11/19/23 at 2:37 PM V2 Director of Nurses stated although R8 has behaviors and can become combative with care, staff should still care for R8's feet and nails. R8 should not have toenails that long. On 11/20/23 at 11:50 AM V2 Director of Nurses confirmed…

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 report a fall to the resident representative, implement post fall interventions, document post fall interventions on the care plan, complete fall risk assessments, and investigate a bruise to identify root cause and interventions. These failures affect two (R28, R49) of seven residents reviewed for accidents in the sample list of 39. Findings include: 1.) On 11/19/23 at 8:42 AM R28 stated R28 does not like R28's wheelchair, it's uncomfortable, and R28 has a bruise on R28's shoulder from the wheelchair. R28 stated R28 has told staff that R28 does not like R28's wheelchair, but nothing has been done. R28 was slouched down in R28's wheelchair. On 11/20/23 at 11:16 AM R28 was slouched down in R28's wheelchair with R28's head resting on the top of the cloth backing of the wheelchair. V18 Certified Nursing Assistant (CNA) stated R28's bruise has been there for 5 days and R28 requires one person assistance for transfers. V18 pulled up R28's shirt…

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 a resident's urinary catheter bag was stored off the floor, failed to obtain orders for a resident's urinary catheter and failed to document urinary catheter care for two of three residents (R8, R21) reviewed for urinary catheters on the sample list of 39. Findings include: The facility's Catheter Care policy dated February 2018 documents catheter care is to be provided on a daily basis and as needed to all residents who have an indwelling catheter to reduce the risk of infection. 1. R8's undated Medical Diagnoses List documents R8 is diagnosed with Schizoaffective Disorder, Dementia, Alzheimer's Disease, Epilepsy, Severe Intellectual Disability, Violent Behavior, and Anxiety Disorder. R8's Physician Order Sheet (POS) documents an order for a urinary catheter to bedside drainage. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. On 11/19/23 at 10:07 AM R8 was sitting in his recliner chair, R8's…

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

Based on observation, interview, and record review the facility failed to date an insulin pen and bottle when opened for two (R26, R15) of 12 residents reviewed for insulin on the sample list of 39. Findings include: The facility's Procurement and storage of medications policy with a revision date of 3/16/23 documents, 7. All medications containers shall be labeled with the date opened by the person breaking the container seal. 1. On 11/21/23 at 8:53 AM, the east hall medication cart contained one Lantus insulin pen for R26. The insulin pen was not dated with an open date. At that time, V9 Registered Nurse confirmed that the insulin pen had been used but not dated when opened. 2. On 11/21/23 at 8:54 AM, the east hall medication cart contained one bottle of Lantus insulin for R15. This insulin bottle was not dated when the bottle was opened. At that time, V9 Registered Nurse confirmed that the bottle was not dated and stated the bottle was delivered on 10/19/23 so it would be over 30 days since delivered.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide routine dental care for one of one resident (R13) reviewed for dental services on the sample list of 39. Findings include: The facility's undated Dental Services policy documents the facility must offer access to necessary routine and emergency dental services to maintain resident dental health. R13's undated Medical Diagnoses list documents R13 is diagnosed with Morbid Obesity, Congestive Heart Failure, Obstructive Sleep Apnea, Emphysema, Paraplegia, and Diabetes. R13's Minimum Data Set, dated [DATE] documents R13 is cognitively intact, has cavities and broken natural teeth, has mouth/facial pain and difficulty chewing, and requires extensive assistance of one person for personal hygiene including brushing his teeth. On 11/19/23 at 10:13 AM R13's teeth were rotting, broken off, or missing entirely. On 11/19/23 at 10:15 AM R13 stated he needs dentures however has only seen a dentist at the facility once since admission. R13 stated…

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

Based on observation, interview and record review the facility failed to serve palatable food for three of three residents (R59, R50, R12) reviewed for palatability of food on the sample list of 39 residents. Findings include: The facility Resident Council Minutes dated 9/1/23 documents new business Meal of the Month: Did not like the hamburgers. They were overcooked. The facility Grievance/Complaint Report dated 10/2/23 documents (V22) (R59's) family member reported (R59) was served burnt grilled cheese at lunch time meal. (V22) stated this is unacceptable and it should have not made it out of the window for anyone. On 11/19/23 12:25 PM R50 stated The food here is awful. It is either raw or burnt or cold. Even when I ask them to heat something it still comes back cold and awful. It is like they don't even have a cook here or anything. The facility Week Two Menu documents 11/20/23 lunch meal as Salisbury steak with gravy, baked potato with margarine, peas and frosted pumpkin bar. On 11/20/23 at 12:45 PM Dietary Staff were serving pumpkin bars with butter cream icing to residents…

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 residents' rights to receive unopened packages delivered to residents in the facility. This failure has the potential to affect all 63 residents residing in the facility. Findings include: The facility Grievance/Complaint log (2023) documents R1 made a complaint related to packages on 9/20/2023. The facility Grievance/Complaint Report form (9/20/2023) documents R1 made a complaint to the facility about resident packages being opened with staff presence. The same record documents re-education was provided to R1 about mail release and appropriate items coming in/out of facility to be monitored by staff. R1's comprehensive assessment (7/13/2023) documents R1 is cognitively intact and capable of making decisions about all areas of R1's life. On 9/26/2023 at 1:36PM, R1 reported facility staff had been opening R1's packages delivered to the facility without R1's permission to check for contraband. R1 reported the facility practice has evolved and R1 is now only allowed to receive unopened packages if R1…

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 provide Transfer and Discharge Notices to residents (R316, R26, R23) and their representatives when being discharged to the hospital. R316, R26 and R23 are three of three residents reviewed for hospitalizations in the sample list of 23. Findings include: 1.) R316's Facility Census Sheet's dated July 2022, September 2022 and October 2022 document R316 being in the hospital on the following three occasions: 7/27/22 through 7/29/22 and returning to the facility on 7/30/22, 9/23/22 through 10/2/22 and returning to the facility on [DATE] and again hospitalized [DATE] through 10/6/22, returning to the facility on [DATE]. R316's Nursing Notes dated 7/27, 9/23 and 10/5/22 do not document R316 and R316's representative being given a Transfer/Discharge Notice. There are no documented Transfer/Discharge Notice forms in R316's medical record. 2.) R26's Facility Census Sheet dated August 2022 documents R26's status as being in the hospital 8/18/22 and returning 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide written Bed Hold Notices to residents (R316, R26, R23) and their representatives when being transferred to the hospital. R316, R26 and R23 are three of three residents reviewed for Hospitalizations in the sample list of 23. Findings Include: 1.) R316's Facility Census Sheet's dated July 2022, September 2022 and October 2022 document R316 being in the hospital on the following three occasions: 7/27/22 through 7/29/22 and returning to the facility on 7/30/22, 9/23/22 through 10/2/22 and returning to the facility on [DATE] and again hospitalized [DATE] through 10/6/22, returning to the facility on [DATE]. R316's Medical Record does not contain Bed Hold Notices for R316's admittance to the hospital on 7/27/22, 9/23/22 and 10/5/22, nor is there documentation a Bed Hold Notice was given. 2.) R26's Facility Census Sheet dated August 2022 documents R26's status as being in the hospital 8/18/22 and returning to the facility on 8/19/22. R26's Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the facility failed to obtain Physician orders for diagnosis, care and changes for R53's Urinary Catheter for one (R53) resident out of two residents reviewed for Urinary Catheters in a sample list of 23 residents. Findings include: R53's Physician Order Sheet (POS) dated November 1-30, 2022, does not document a medical diagnosis for R53's Urinary Catheter. R53's Care Plan dated 7/15/22 documents a focus area of Alteration in Bladder Elimination with Indwelling Catheter. R53's Minimum Data Set (MDS) dated [DATE] documents R53 as being cognitively intact. This same minimum data set (MDS) documents R53 as having an indwelling urinary catheter. R53's Treatment Administration Record (TAR) dated November 1-30, 2022, does not document a physician order for R53's Urinary Catheter size nor date to change. On 11/15/22 at 12:30 PM R53 was wheeling self in the wheelchair down the hallway with a Urinary Catheter drainage bag hanging from bottom of the wheelchair. On 11/18/22…

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.