Goldwater Care Clinton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Failures at this level required more than one deficient practice statementA. Based on interviews and record reviews the facility failed to ensure follow up medical appointments were scheduled for one (R3) of one resident reviewed for medical appointments in the sample of seven residents.B. Based on interview and record review the facility failed to ensure neurological assessments were completed for one (R5) of one resident reviewed for incidents involving a head injury in the sample of seven residents.Findings include:a. R3's record review documents an admission date of [DATE] and a discharge date [DATE] with diagnosis of Ascites, Cirrhosis, Liver Mass, Dementia, Ascites of Liver and Type 2 Diabetes Mellitus. Further record review documents R3 was admitted to hospice care on [DATE] with the terminal illness Dementia and a Liver Mass. On [DATE] at 10:10am, V15 Hospice Nurse confirmed the facility should have scheduled and transported R3 to a treatment center if paracentesis was needed. V15 confirmed that R3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect residents (R1 & R5) from physical abuse from another resident (R2). This failure affected two (R1 & R5) of three residents reviewed for abuse in the sample list of five residents. Findings include:On 3/21/2026 at 8:37 AM, R1 was observed walking down the hallway independently without an assistive device. R1 was clean and well-groomed. R1 then walked around the dining room with other residents still eating. R1 was observed going from one table to another. R1 then sat down on a chair in the dining room. After a few minutes, R1 got up and started to wander around the dining room again while other residents were still eating. R1 was unable to understand what was being asked during the interview due to cognitive impairment. R1's was observed to have a healed wound to right forearm.On 3/21/2026 at 8:40 AM, V2 Certified Nurse Assistant (CNA) stated R1 wanders around and is not able to see very well but usually is not aggressive.On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse to the State Agency for two (R2, R5) residents out of three residents reviewed for abuse, on a sample list of five residents.Findings include:R2's Care Plan date initiated 8/25/2025 documents focus Problematic manner in which I (R2) act characterized by ineffective coping; verbal/ physical Aggression related to: Cognitive impairment/physiological changes in brain.R2's Minimum Data Set (MDS) dated [DATE] documents R2's cognition is severely impaired.R5's Care Plan initiated 3/3/2026 documents focus Problematic manner in which I (R5) act characterized by ineffective coping; verbal/physical Aggression related to: Cognitive impairment/physiological changes in brain (verbal abuse with staff and residents).R5's Care plan date initiated 3/3/3026 documents focus Problematic manner in which I (R5) act characterized by inappropriate behavior; Hoarding and Rummaging related to: Cognitive impairment onset of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to investigate allegations of resident-to-resident physical abuse for two (R2, R5) out of three residents reviewed for abuse, on a sample list of five residents.Findings include:The Facility's Abuse Prevention and Reporting Policy with revised date 10/24/22 documents all incidents will be documented whether or not abuse was alleged or suspected. Any incident or allegation involving abuse will result in an investigation.R2's Nurse's Note dated 2/25/2026 documents R2 has an alleged physical altercation with another residentR2's Care plan dated initiated 3/2/2026 documents focus I (R2) have the potential to be physically aggressive r/t (related to) Anger, Dementia, Depression, History of harm to others, and Poor impulse control.R2's Care Plan initiated 8/25/2025 documents focus Problematic manner in which I (R2) act characterized by ineffective coping; verbal/ physical Aggression related to: Cognitive impairment/physiological changes in brain.R2's Minimum…

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

Based on interview, and record review, the facility failed to provide a registered nurse for eight consecutive hours daily. This failure has the potential to affect all 104 residents of the facility. Findings include:On 2/9/26 at 10:10am V1, Administrator, stated the facility does not have a stand-alone staffing policy and follows the minimum guidelines for nurse staffing hours including registered nurse coverage. On 2/9/26 V1, Administrator, provided nursing staffing sheets that document the facility nurses work twelve (12) hour shifts. On the following dates per the provided nurse staffing sheets, no registered nurse coverage was scheduled or available in the nursing facility:1/3/26; 1/4/26; 1/17/26; 1/18/26; 1/31/26; 2/1/26.On 2/10/26 at 3:50pm V18, Former Director of Nursing, stated V18's last day of employment in the facility was 1/30/26. V18 stated the facility did not always have a registered nurse available especially on weekends. V18 stated the facility used agency nurses to fill in when house nursing staff were unavailable, and agency Registered nurses were not always…

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 performance review of every nurse aide at least once every 12 months, and to provide regular in-service education based on the outcome of these reviews. This failure has the potential to affect all 104 residents of the facility. Findings include:On 2/9/26 review of Facility Assessment (FA) dated 2/6/26 documents: Abuse, neglect, and exploitation - training that at a minimum educates staff on: (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; Reporting of Crimes (Elder Justice Act) and (3) Care/management for persons with dementia and resident abuse prevention.The FA further documents: Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. On 2/11/26 at 1:05pm V1, Administrator, and V14, Interim DON/Regional 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 observation, interview, and record review, the facility failed to document food preparation temperatures on the food temperature log labeled for the main kitchen food preparation. This failure has the potential to affect all 104 residents of the facility. Findings include:On 2/8/26 at 08:10 AM, review of the main kitchen food temperature log revealed it did not contain logged food temperatures for breakfast and lunch meals for 2/5/26 and 2/6/26, and for breakfast on 2/8/26.The undated Food & Beverage Temperature Control policy documents:Purpose: To ensure residents receive safe food served at acceptable temperatures.Procedure: Food and beverage temperatures should be taken and logged upon being cooked and again prior to meal service.Documentation: Log cook and service (holding) temperatures.On 2/8/26 at 08:10 AM, V39, Cook, stated V39 did not know why the temperatures were not logged on the food temperature logs.On 2/10/26 at 1:10 PM, V3, Dietary Manager, confirmed the temperature logs should have been completed at the time of cooking the food for consumption. V3 stated V3…

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 staff members attended Quarterly Quality Assurance meetings. This failure has the potential to affect all 104 residents residing in the facility. Findings:The Long-Term Care Facility Application for Medicare and Medicaid form dated 2/08/26 documents that 104 residents reside in the facility.The facility's Quality Assurance Performance Improvement Program (QAPI) Policy dated 11/28/12 with a revision on 10/24/22 documents that the committee shall meet at least quarterly to assure activities are performed and identified problems have corrective actions taken or an appropriate action plan is developed as indicated.This policy documents that the committee members include, but are not limited to, Administrator (Chairperson), Medical Director, Director of Nursing, Infection Preventionist, Wound Care Nurse (as applicable), Social Services Director, Activities Director, Dietary Manager, Housekeeping/Laundry Director, Maintenance Director, Human Resources, MDS Coordinator, and other ancillary services (Pharmacy,…

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

Based on observation, interview, and record review the facility failed to ensure proper infection prevention and control practices related to oxygen administration for one (R73) of three residents reviewed for Respiratory Care out of a sample list of 45 and the facility failed to accurately document and analyze facility infections. This failure has the potential to affect all 104 residents currently residing at this facility.Findings:1. R73's undated Care Plan documents an admission date to the facility of 7/13/2023 with the following diagnoses: Malignant Neoplasm of Colon, Unspecified; Vitamin Deficiency, Unspecified; Hyperlipidemia; Excoriation Disorder; Squamous Blepharitis.R73's Minimum Data Set (MDS) Section C, dated 01/25/2026, documents R73 with a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment.On 2/08/2026 at 9:34 AM, R73 was sitting in a wheelchair with a nasal cannula applied, with the other end of the cannula attached to a portable oxygen tank hanging on the back of R73's wheelchair. The nasal cannula applied to R73's nose was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to designate one or more individuals as infection preventionist. This failure has the potential to affect all 104 residents currently residing at this facility.Findings:The facility's Long-Term Care Application for Medicare and Medicaid dated [DATE] documents a total of 104 residents.On [DATE] at 9:17 AM, V12, Acting Director of Nursing (DON), stated the facility does not currently have a certified Infection Preventionist. V12 further stated that her certification has expired and she is currently working on completing the required tasks to obtain her Infection Control Certification.The undated Department Head list does not include an employee listed as Infection Control and Prevention.

Based on interviews and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training for staff. This failure has the potential to affect all residents residing in the facility. Findings:The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 2/08/26 documents a total census of 104 residents.The Facility Assessment Tool, which is undated, documents that the facility will provide staff with the necessary training, education, and competencies to deliver the level and types of care required for its resident population. This assessment tool includes a list of training topics, which specifically references the Quality Assurance and Performance Improvement (QAPI) program.On 2/17/2026 at 10:32 a.m., V1, Administrator stated he could not provide documentation showing that QAPI training for staff had been completed. V1 further stated he was not aware that QAPI training was required for staff and commented, I haven't done that type of training here or at any other facility I've been at.

Based on Interview and record review the facility failed to provide behavioral health training to all direct care staff. This deficiency has the potential to affect all resident who reside in the facility.Findings Include: The facility's Long-Term Care Application for Medicare and Medicaid dated 2/8/26 documents the census as 104 residents residing at the facility.On 2/17/26 at 10:00AM V1, Administrator and V14, Acting DON (Director of Nursing) verified they cannot provide documentation of Behavioral Health training for any staff was conducted in the 12 months previous to this survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to honor residents' right to make choices regarding the timing of their showers. This failure affects three residents (R11, R23, and R45) out of three residents reviewed for personal care choices, from a total sample of 46.The facility's Bathing - Shower and Tub Bath Policy dated 11/28/12 with a revision on 1/31/18 documents that the purpose of this policy is to ensure resident's cleanliness to maintain proper hygiene and dignity. The policy requires that residents be offered a shower, tub bath, or bed/sponge bath according to their individual preferences for timing and frequency, at least twice per week, and additionally as requested or needed.R11's Electronic Medical Record (EMR) documents that R11 was admitted to the facility on [DATE] for aftercare following joint replacement surgery of the right hip on 12/01/25.R11's Minimum Data Set (MDS) dated [DATE] documents that R11's cognition is intact and that R11 is dependent on staff for showers. R11'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 a multi dose insulin pen when opened for one (R56) of five residents reviewed for medication administration on the sample list of 46.Findings include: On 2/09/2026 at 12:13 PM, V12 Licensed Practical Nurse administered 10 units of Insulin Aspart to R56 using a multi-dose insulin pen. This insulin pen had previously been opened and used and was not dated. At that time, V12 confirmed that R56's multi dose insulin pen had been previously opened and not dated when opened. V12 stated the opened insulin pen should be dated. The facility's Injectable Medication Administration policy with the revision date of November 2021 documents a procedure to date injectable medication when opened.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure influenza and pneumococcal vaccinations was offered and documented in the medical record. This failure affected five of five (R15, R4, R2, R63, and R12) residents reviewed for Infection Control out of a sample list of 46.1.R15's undated Care Plan documents an admission date to the facility as 02/11/2025 with the following diagnosis: Iron Deficiency, Lipoprotein Deficiency, Vascular Dementia, Mild, With Anxiety, Depression, Restless Legs Syndrome, And Chronic Pain.R15's medical record does not document that a pneumococcal vaccine nor a influenza vaccine was offered to R15. R15's Minimal data set dated [DATE] documents R15 with a Brief Interview for Mental Status score of six indicating severe cognitive impairment.R15's medical record does not document that a pneumococcal nor an influenza vaccine was offered to R15.On 2/17/2026 at 10:32 AM V41, R15's family member, stated she does not recall being informed of immunizations during the admission…

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 COVID-19 vaccinations are offered and documented. This failure affected five of five (R15, R4, R2, R63, and R12) residents reviewed for Infection Control out of a sample list of 46.Findings:1.R15's undated Care Plan documents an admission date to the facility as 02/11/2025 with the following diagnosis: Iron Deficiency, Lipoprotein Deficiency, Vascular Dementia, Mild, With Anxiety, Depression, Restless Legs Syndrome, And Chronic Pain.R15's medical record does not document that a pneumococcal vaccine nor a influenza vaccine was offered to R15. R15's Minimal data set dated [DATE] documents R15 with a Brief Interview for Mental Status score of six indicating severe cognitive impairment.R15's medical record does not document that a COVID-19 immunization was offered or administered to R15.On 2/17/2026 at 10:32 AM V41, R15's family member, stated she does not recall being informed of immunizations during the admission process at this facility.On…

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

Based on interview and record review the facility failed to obtain consents for psychotropic medications for one (R17) of five residents reviewed for unnecessary medications on the sample list of 46.Findings include: R17's medical record contains an order dated 4/13/2025 for Olanzapine (anti-psychotic medication) 2.5 milligrams (mg) one tablet orally at bedtime, an order dated 2/6/2025 for Citalopram Hydrobromide (anti-depressant) 10 mg one tablet daily and an order dated 4/13/2025 for Trazodone (anti-depressant) 100 mg one tablet at bedtime. R17's medical record does not contain consents for these medications. On 2/10/2026 at 9:00 AM, V1 Administrator stated there were no consents for R17's use of psychotropic medications. The facility's psychotropic medication policy with revision date of 2/01/2018 documents psychotropic medication shall not be administered without the informed consent of the resident and/or resident's representative.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and record the facility failed to notify the physician and dietician of a significant weight loss for one (R112) of three residents reviewed for physician notification in the sample list of 46. Findings include:R112 's diagnosis list (printed 2/11/26) documents that R1's diagnoses include Dementia, Syncope (fainting) and Collapse, Difficulty in Walking, Muscle Wasting and Atrophy, Pain, Cognitive Communication Deficit, Depression, and Anxiety.R112's Resident assessment dated [DATE] documents R1 has severely impaired cognition and requires substantial/maximal staff assistance for transfers, including going from a seated position to a standing position. The same record documents R1 does not have behaviors, delusions, or hallucinations.R112's undated weight list documents on 2/1/2026 at 09:52am R112 weighed 128.2 pounds and on 1/5/2026 at 11:37am R112 weighed 137.0 pounds, a weight loss of 6.6%.On 2/9/26 review of Weights Policy dated 10-17-19 revised documents the following: Guidelines:I. Each…

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 right to be free from chemical restraints by failing to implement alternatives to psychotropic medications, failing to monitor for tardive dyskinesia, and failing to gradually reduce psychotropic medication for one (R17) of five residents reviewed for unnecessary medications on sample list of 46. Findings include: The facility's Psychotropic Medication-Gradual Dosage Reduction policy with a revision date of 2/1/18 documents residents are not given psychotropic drugs unless necessary. This policy documents the plan to alternatives to psychotropic medications shall be incorporated into the care plan with suitable goals and approaches. This policy documents residents on anti-psychotic drug therapy will be monitored for tardive dyskinesia side effects every six months through the use of the AIMS (Abnormal Involuntary Movement Scale). This policy also documents that gradual dose reductions will be attempted at least twice yearly and the physician will document a clinical rationale if a reduction is declined. R17's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately code a minimum data set assessment for one (R17) of 32 residents reviewed for assessments on the sample list of 46. Findings include: R17's medical record documents R17 was sent to the hospital and diagnosed with a left arm fracture on 10/9/2025 following a fall that same day. R17's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R17 has fallen since the last assessment and documents a zero for major injuries since the last assessment. On 2/08/2026 at 9:49 AM, V15 MDS Coordinator stated the fall with fracture that occurred on 10/9/25 is a major injury and should have been captured on R17's 11/15/25 quarterly MDS assessment.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a care plan for constipation for two (R1, R17) of 32 residents reviewed for care plans on the sample list of 46. Findings include: 1. R1's medical record documents R1 was admitted to the facility on [DATE] with a diagnosis of Constipation. R1's Progress Note dated 10/31/25 written by V39 Nurse Practitioner documents a plan to monitor bowel movements daily, give laxative and/or stool softener as needed for constipation, notify provider if no bowel movement within three days, increase hydration, fiber intake, and physical activity, and to limit narcotic use. R1's Care Plan with revision date of 9/5/25 does not include a plan of care or interventions for constipation. On 2/09/2026 at 11:41 AM, V14 Interim Director of Nursing (DON) stated there should be a care plan developed addressing the constipation for R1. V14 stated R1 does not have a care plan for constipation. 2. R17's Physician's Order Sheet documents an order dated 10/10/25 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 update a residents Care Plan to include a significant weight loss for one of 46 residents (R81) reviewed for Care Plans on the sample list of 46. Findings Include: R81's Census form dated 2/17/26 documents R81's admission date as 7/11/25. R81's weights are documented from 7/13/25 to 2/9/26 in the EMR (Electronic Medical Record). R81's weight on 7/13/25 was 175.0 pounds. R81's weight on 2/9/26 was 114.6 pounds which equals R81 losing 60.4 pounds. R81's care plan dated 2/4/26 does not address R81's weight loss. V15, Care Plan Coordinator stated on 2/12/26 at 2:30 PM I did not realize the care plan did not document the weight loss. I know we addressed (R81) needing a special diet, but we did not document anything about weight loss. The facility's policy titled Comprehensive Care Plan with revision date of 11/17/17 states, To develop a comprehensive care plan that directs the care team and incorporates the resident's goals preferences, and services that are to be furnished to attain or maintain the resident's highest practicable…

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 neurological checks after an unwitnessed fall and a fall with a head injury for one (R112) of three residents reviewed for assessments in a sample list of 45. Findings include:On 2/9/26 review of Fall Prevention Program dated Revisions: 11-21-17 documents Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Standards: A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident. The same policy further documents Documentation in nurses' notes is to include the following a. A description of the occurrence, the extent of injury (if any), the assessment of the resident, vital signs, treatment rendered, and parties notified. b. A minimum of seventy-two…

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 implement resident centered interventions for one resident with dementia (R7) of six residents reviewed for Dementia in a sample of 46.Findings Include: R7's Care Plan, updated 11/6/25, documents the following diagnoses: Type II Diabetes, Alzheimer's Dementia, Repeated Falls, and Major Depression.R7's Minimum Data Set (MDS) dated [DATE] documents that R7 has no behavioral symptoms.On 2/8/26 at 9:00 AM, R7 was in his bed watching TV. The Surveyor knocked on R7's open door. R7 shouted, What and who the H* are you? The Surveyor introduced herself and explained to R7 that she was here from IDPH (Illinois Department of Public Health) to talk with residents about the care they receive at the facility. R7 seemed very agitated and shouted, Well, if you are from the F (expletive) state, get me out of here now. I am being held prisoner. That F (expletive) B (expletive) had them arrest me. The Florida state police went into Georgia…

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

Based on observation, interview and record review the facility failed to administer medications as ordered by the physician for one (R111) of five residents reviewed for medication administration on the sample list of 46. These failures resulted in two medication errors out of 29 opportunities resulting in a 6.9% medication error rate. Findings include:On 2/09/2026 at 8:45 AM, V10, Licensed Practical Nurse, was pulling R111's medications out of the medication cart. At that time, V10 stated she did not have Calcium 600 milligrams or Omeprazole 20 milligrams to administer to R111. V10 stated the facility does not have these medications in stock. V10 confirmed that the Omeprazole and Calcium were not administered as ordered by the physician.R111's Medication Administration Record for February of 2026 includes an order dated 1/13/26 for calcium 600 milligrams, give one tablet by mouth one time a day, and an order dated 10/17/25 for omeprazole 20-milligram capsule, one capsule a day. This administration record documents see progress note under the administration box for the calcium and…

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

Based on observation, interview, and record review the facility failed to ensure liquids provided at the bedside were thickened as ordered by the physician for one (R107) of 32 residents reviewed for hydration on the sample list of 46.Findings include:R107's physician's order dated 12/23/25 documents R107 is to receive nectar thickened liquids. R107's care plan with a revision date of 12/24/25 documents R107 requires nectar thickened liquids. On 2/08/2026 at 11:25 AM, a glass of thickened liquids and a glass of regular water were sitting on R107's bedside table. R107 stated she took her morning medications with the glass of regular water and not the thickened liquids. On 2/08/2026 at 1:38 PM, V6 Licensed Practical Nurse confirmed that R107's liquid order is nectar thick and that R107 should not have regular water at the bedside. On 2/08/2026 at 1:48 PM, the glass of regular consistency water was still sitting on R107's bedside table. On 2/08/2026 at 1:51 PM, V8 Certified Nurse Assistant stated R107 is not able to get up on her own and get her own water and that a staff member would…

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 use the services of a Registered Nurse (RN) for at least eight consecutive hours a per day. This failure has the potential to affect all 107 residents in the facility. Findings Include: Facility Nursing Staff Schedules reviewed from 12/17/25 through 1/7/26 documented five days (12/20, 12/21, 12/26, 12/29, 12/30/25) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 1/7/26 at 11:50 AM V2 Director of Nurses (DON) confirmed the facility did not have eight hours of Registered Nurse coverage every day and needed to hire more RNs in order to meet the requirement. V2 also confirmed the facility's current census was 107 residents. The facility's Facility assessment dated [DATE] documents a Registered Nurse is needed every day in order to provide competent support and care for the facility's resident population. The Central Management Services 802 Matrix dated 12/23/25 documents the facility has a census…

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 resident rights to dignified care for four of five residents (R5, R8, R9 and R10) reviewed for dignified care on the sample list of 30.Findings include:1. R8's Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview of Mental Status score as 13 out of a possible 15, indicating no cognitive impairment. The same MDS documents R8 is frequently incontinent of bowel and bladder.On 12/24/25 at 1:35 p.m., R8 stated to this surveyor that on the overnight of 12/22/25, she put on her call light to be toileted. Two unidentified agency Certified Nursing Assistants (CNAs) passed by her room while the call light was on. They said nothing to me as they passed by. R8 stated she waited and waited and figured the staff were just busy. R8 stated she had taken Tylenol and Gabapentin earlier that night-medications that can cause drowsiness-and fell back to sleep with the call light on.R8 stated, I woke up again and was very wet. I was soaked in urine. My…

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 repeatedly failed to honor residents' preference to choose the shift their showers would be scheduled, and repeatedly failed to provide dependent residents with showers. These failures affected five of five resident (R2, R3, R9, R24, and R26 ) resident reviewed for showers on the sample list of 30. Findings include:1.R2's current Diagnoses sheet documents the following: Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites and Other Lack Of Coordination.R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status score as 14 out of a possible 15, indicates no cognitive impairment. The same MDS documents R2 has had no behavior and has not declined care.R2's Care Plan dated 11/24/25 documents R2 has a potential for skin impairment and directs staff to keep resident clean and dry. The same care plan documents R2 requires partial to moderate assistance with shower/bathing.R2's shower sheet document R2 is…

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 order, failed repeatedly to obtain medications from the pharmacy in a timely manner, and failed to administer a resident's pain medications. These failure affected three of five residents (R7, R9 and R24) reviewed for medications on the sample list of 30. Findings Include: 1.R7's Hospital Discharge After Visit Summary documents R7 was discharged to the facility on [DATE], status post left total knee replacement surgery. Discharge orders included instructions to follow physician orders for medications to control pain. R7's pain medication orders included hydrocodone 5/325 mg, take one to two tablets by mouth every four hours as needed for moderate to severe pain; hydromorphone 4 mg by mouth every four hours as needed for moderate to severe pain; morphine 15 mg by mouth every 12 hours; and tizanidine 4 mg, two tablets by mouth every six hours as needed for muscle spasms. R7's medical diagnoses include chronic pain status post motor vehicle injury, morbid…

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 repeatedly to administer muscle relaxer/pain/medication, resulting in a significant medication error for one of nine residents (R24) reviewed for medications administration on the sample list of 30.Findings include:R24's current Diagnoses sheet documents the following: Wedge compression fracture of T9-T10 vertebra, subsequent encounter for fracture with routine healing; restless leg syndrome; chronic pain syndrome; muscle wasting and atrophy, not elsewhere classified; and other abnormalities of gait and mobility.R24's Minimum Data Set (MDS) dated [DATE] documents R24's Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment. The same MDS documents R24 experiences occasional, moderate pain that frequently interferes with activities and sleep.R24's current physician Order Summary sheet documents the following medication order: Methocarbamol oral tablet 750 mg, give one tablet by mouth three times a day 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a resident with an active, symptomatic pneumonia infection was placed on isolation precautions to prevent transmission of a bacterial infection, and repeatedly failed to ensure a second resident was not subjected to the exposure of the respiratory infection while treatment was delayed for four days, then while treatment was in progress for a total of 10 days. This failure affected two of six residents (R3 and R4) reviewed for transmittable infections on the sample list 30.Findings include:R3's Minimum Data Set (MDS) dated [DATE] documents the following: R3's Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment.On 12/26/25 at 2:50 p.m., R3 stated, My complaint about (R4) was that she (R4) was brought into my (R3) room as my new roommate. She was actively coughing all the time. She had pneumonia, and staff knew it. No one wore gowns or masks. It was terrible. She coughed constantly. I am in my bed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify a resident's physician of a significant change of condition (severe increase is pain). This failure affected one of five residents (R7) reviewed for pain on the sample list of 30.Findings Include: R7's Hospital Discharge After Visit Summary documents that R7 was discharged to the facility on [DATE], status post left total knee replacement surgery. Discharge orders included instructions to call the physician's office for any severe, uncontrolled pain. R7's pain medication orders included Hydrocodone 5/325 mg, take 1-2 tablets by mouth every four hours as needed for moderate or severe pain. Additional pain medication orders included Hydromorphone 4 mg by mouth every four hours as needed for moderate to severe pain; Morphine 15 mg by mouth every 12 hours; and Tizanidine 4 mg, two tablets by mouth every six hours as needed for muscle spasms. R7's medical diagnoses included chronic pain status post motor vehicle injury, morbid obesity, and left knee…

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 recognize an allegation of abuse and report the allegation to the State Agency. This failure affected one of eight residents (R8) review for abuse/misappropriation on the sample list of 30.Findings include:The facility's Grievance Tracking Log dated November 2025 documents that R8 filed a grievance on 11/06/25. The tracking log does not document any additional information regarding the grievance.The facility's Grievance Concern/Compliment Form dated 11/6/25 documents that V23, Housekeeper/Laundry Supervisor, was the staff member who received the report. Under Nature of Concern/Compliment (Complaint), the form documents: Resident (R8) stated a CNA, described as a 'heavier-set (race) girl,' needed an upgrade, as she threw clothes at the resident and stated the resident needed to get herself dressed and put herself in her wheelchair.R8's Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview of Mental Status score as 13 out of a possible 15,…

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 use the services of a Registered Nurse (RN) for at least eight consecutive hours a per day. This failure has the potential to affect all 104 residents in the facility. Findings Include: Facility Nursing Hall Assignment Sheets reviewed from 8/27/25 through 9/15/25 documented nine days (8/27, 8/28, 9/2, 9/3, 9/4, 9/9, 9/11, 9/13, 9/14) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 9/18/25 at 2:30 PM V1 Administrator confirmed there were days with no RN staffing available. V1 also confirmed the facility's average daily census was around its current census of 104 residents. The Bed Management sheet dated 9/10/25 documents a current census of 104 residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide multiple scheduled showers for dependent residents. This failure affected three of three residents (R6, R8, R9) reviewed for showers on the sample list of 19. Findings Include: Facilities Bathing - Shower and Tub Bath Policy dated January 2018 documents: Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference, two times per week or according to the resident's preferred frequency and as needed or requested. Staff are to document bathing task and assistance provided in the electronic record, including pertinent observations. 1. R6's Medical Diagnoses list dated September 2025 documents R6 is diagnosed with Unspecified Dementia, Generalized Anxiety, Parkinson's Disease, Insomnia, Pressure Ulcer of the Sacral Region, Overactive Bladder, Congestive Heart Failure, and Abnormalities of the Gait and Mobility. R6's Minimum Data…

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 multiple wound dressing treatments and failed to address a residents repeated refusals for wound treatment. This failure affected one of three residents (R9) reviewed for wounds on the sample list of 19. Findings Include: The facility's Pressure Injury and Skin Condition assessment dated [DATE] documents the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown and assuring interventions are implemented. Dressing should be changed in accordance with physician orders and documented in the Treatment Administration Record (TAR). Physician ordered treatments shall be initialed by the staff on the electronic TAR after each administration. R9's Medical Diagnoses list dated September 2025 documents R9 is diagnosed with Dementia, Delusional Disorder, Depression, Need for Assistance with Personal Care, and Malignant Neoplasm of unspecified Site of Right Female Breast. R9's Physician…

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 (R3) to be free of physical abuse from (R2) for two of six residents reviewed for abuse in the sample list of 19.Findings include:R2's Abuse/Neglect Screening form dated 5/1/25, documents R2 has a history of mistreating others by physical and verbal abuse, psychiatric mental health issues which include psychotic symptoms, and documents R2 cries a lot and them becomes angry with other residents.R2's undated diagnoses list documents the following diagnoses: other specified Anxiety Disorder, and Alzheimer's Disease, unspecified. R2's Progress Note/Psychotropic dated 8/21/25, documents R2's diagnoses as: Major Depressive Disorder, Dementia in other diseases classified elsewhere, severe, with Agitation, and Anxiety with somatic features.R2's Minimum Data Set (MDS) dated [DATE], documents R2 is not cognitively intact.R2's Care Plan dated 8/27/25, documents R2 has a problematic manner characterized by ineffective coping,…

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 conduct a fall investigation, develop a root cause, and implement relevant fall interventions for one resident (R4) of three residents reviewed for falls in the sample list 19. This past non-compliance occurred from 8/9/25 to 8/19/25.Findings include:R4's undated diagnoses list documents R4's diagnoses as: Cellulitis of Right Lower Limb, other Chronic Pain, other Lack of Coordination, and need for assistance with Personal Care.R4's Minimum Data Set (MDS) dated [DATE], documents R4 requires supervision or touching assistance with walking. R4's Psychiatric Notes dated 8/5/25, documents R4 has thought blocking process and poor insight.R4's Minimum Data Set (MDS) dated [DATE], documents R4 in not cognitively intact.R4's Care Plan dated 7/14/25, documents R4 has Impaired Cognitive Function or Impaired thought Processes related to Dementia with interventions to cue, reorient, and supervise as needed. This same Care Plan documents R4 is at high risk 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 ensure resident records were accurately documented and maintained for five residents (R12, R13, R14, R15, R16) of five residents reviewed for documentation in the sample list of 19.Findings include:The facility's Employee Disciplinary Form dated 7/22/25, documents V12 Certified Nursing Assistant (CNA), received a final warning regarding incomplete documentation. This report documents five residents (R12, R13, R14, R15, R16) were audited with 10 Activities of Daily Living (ADL) examples, totaling 40 occurrences of mis-documentation occurring in the past 30 days. This form documents R12 having 6 occurrences, R13 having 16 occurrences, R14 having 6 occurrences, R15 having 10 occurrences, and R16 having two occurrences of mis-documentation. On 9/17/25 at 10:13 AM, V1 Administrator, stated V12 CNA had been terminated on 9/15/25, due to false charting previously for documenting giving baths but did not do the baths.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide consistent quality care for five of eight residents (R1, R2, R5, R6, R7) reviewed for nursing care on the sample list of eight. Findings Include: The Facility assessment dated [DATE] documents all medical and non-medical supplies needed and ordered by the physician will be provided to the resident in a timely manner. If equipment is not in the facility, it will be ordered and provided, borrowed from a sister facility or rented to endure the needs of the residents are met. Staffing is adjusted based on resident census and acuity. Resident preferences and suggestions are elicited during resident council meetings and will be taken into consideration. Concerns will be addressed as appropriate and the need for additional staff will be considered to meet the needs of the residents in the facility. The facility's March 2025 Grievance Log and Resident Council Minutes document resident concerns with not getting scheduled showers. The summary of findings,…

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 linens and incontinence briefs for three of seven residents (R5, R6, R7) reviewed for resident preferences from a total sample list of seven residents. Findings include: 1.) On 5/5/25 at 9:37 AM R5 stated the facility ran out of her size briefs the weekend of April 26-27, 2025. R5 stated that they gave her a smaller size to use which was uncomfortable. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively intact. On 5/5/25 at 9:40 AM R6 stated about a week or so ago they ran out of several sizes of briefs. They gave her a smaller size and she wasn't able to fasten them. R6's Minimum Data Set, dated [DATE] documents R6 is moderately cognitively intact. The facility provided purchase order dated 4/25/25 documents a rush order submitted at 9:20AM for extra large briefs, large briefs, ultra size briefs, and medium size briefs. On 4/30/25 at 9:35AM V4 Certified Nursing Assistant (CNA) stated that she worked on Friday (4/25/25)…

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 ordered dressing changes and failed to accurately document worsening pressure wound staging for three (R2, R3, and R4) of four residents reviewed for pressure wounds from a total sample list of seven residents. Findings include: The facility provided Pressure Injury and Skin Condition assessment dated [DATE] documents the facility policy is to assess, monitor, and document the presence of skin breakdown, pressure injuries, and other ulcers and to insure that interventions are implemented. Pressure and other ulcers will be assessed and measured at least every seven days and documented in the resident's clinical record. Physician ordered treatments shall be initialed by the staff on the treatment administration record after each administration. 1.) R4's wound report dated 2/1/25-4/30/25 documents R4 has a facility acquired skin tear on the right outer ankle, identified on 4/10/25. On 4/30/25 at 1:20PM, V3 Wound Nurse stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications as ordered resulting in repeated significant medication errors for two (R1, R2) of three residents reviewed for significant medication errors from a total sample list of seven. Findings include: The facility provided Medication Preparation and General Guidelines Policy dated December 2019 documents that it is the policy of the facility to administer medications as prescribed. Medications are administered within 60 minutes of scheduled times. Current medications are listed on the Medication Administration Record (MAR) and the MAR is initialed by the person administering the medication, in the space provided under the date. If a scheduled medication is not given, an explanation is documented. R1's undated diagnosis sheet documents R1's diagnoses include: Epilepsy, Primary Hypertension, and Venous Thrombosis with Embolism. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. On 4/30/25 at 11:33AM, R1 stated there…

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 dignity of one (R1) of three residents reviewed for dignity from a total sample list of seven residents. Findings include: The facility provided Dignity Policy dated 4/23/18 documents that the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and a respect in full recognition of his or her individuality. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. R1's undated diagnosis sheet documents R1's diagnoses include: Epilepsy, Primary Hypertension, and Venous Thrombosis with Embolism. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact. On 4/30/25 at 11:33AM, R1 stated there have been several times when she doesn't receive her medications and that it is usually from an agency nurse who she doesn't know. R1's physician order dated 2/3/25 documents Keppra (anti-seizure)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications according to physician orders for two of three residents (R1, R2) reviewed for medication administration in the sample list of seven. Findings include 1.) The facility provided Medication Preparation and General Guidelines Policy dated December 2019 documents that it is the policy of the facility to administer medications as prescribed. Medications are administered within 60 minutes of scheduled times. Current medications are listed on the Medication Administration Record (MAR) and the MAR is initialed by the person administering the medication, in the space provided under the date. If a scheduled medication is not given, an explanation is documented. R1's April/May 2025 medication administration record documents orders for Amiloride (potassium sparing medication) 10 Milligrams (MG) daily, Celexa (antidepressant) 20 MG daily, Cranberry tablets (urinary health) 400MG daily, Fiber-Lax (constipation preventative) 625MG daily, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide and implement activities to meet the interests and needs of the residents. This failure affects five (R1, R2, R3, R4, and R5) of five residents reviewed for activities on the sample list of five. Findings Include: On 1/28/25 intermittent observations were done between 10:05am and 2:20pm. R1 through R5 were observed between 10:05am and 10:20am sitting at tables in the dining/activity area participating in various activities (reading, puzzles, coloring, and folding). At 2:15pm, R2, R3, and R5 were observed sitting at the same tables they had been observed at 10:05am and 12:26pm in the dining/activity area with their empty lunch dishes still on the table. Residents were not observed in any group activities during these observations and no other individual activities observed while on the unit. There is no documentation in the Memory Care Unit Activity Binder for R1, R2, R3, R4, or R5 for the month of January 2025. This binder contains…

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 Resident Council grievances were resolved in a timely manner. This failure had the potential to affect all 90 residents who reside in facility. Findings include: The facilities Grievance Policy revised 6/1/2022 documents residents have the right to voice grievances to the facility and grievances shall be addressed by the facility in a timely manner. Resident Council Minutes dated 1/8/24 document under old business concerns with cell phone and ear bud usage, call lights not being answered timely, and certified nursing assistants (CNAs) are loud in hallways. Resident Council Minutes for 3/11/24 document under new business concerns with second shift CNAs on phones during meals and rude attitudes when answering call lights with what do you want. Resident Council Minutes dated 4/1/24 document phone usage during resident cares is still a concern. Resident Council Minutes dated 6/3/24 document CNAs are always on their phones. Resident Council Minutes dated 7/8/24 document CNAs are on their phones once managers leave.…

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

Based on interview, and record review, the facility failed to document receiving registry verification that the employee has met eligibility requirements to work in the facility prior to start date. This failure has the potential to affect all 90 residents residing in the facility. Findings include: The facility census sheet dated 12/2/24 documents there are 90 residents who reside at the facility. On 12/3/24 at 10:00 AM employee V32 Certified Nursing Assistant (CNA), V33 CNA, V34 CNA, V35 CNA, V36 Cook, V37 Resident Aide employee files were reviewed for documented evidence of Illinois Health Care Worker registry eligibility to work in a healthcare facility. None was obtained from the employee files. Timecard reprint dated 12/3/24 at 11:47 AM documents V34 first day of employment was 11/20/23. Illinois Healthcare Worker Registry added to the employee file documents it was checked on 12/3/24. Timecard reprint dated 12/3/24 at 11:53 AM documents V33 first day of employment was 11/20/23. Illinois Healthcare Worker Registry added to the employee file documents it was checked on 12/3/24.…

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 conduct and document an accurate facility assessment. This failure has the potential to affect all 90 residents who reside at the facility. Finding Include: The facility census sheet dated 12/2/24 documents there are 90 residents who reside at the facility. 1. The facility assessment dated [DATE] Section A.1 states This facility has the following equipment to meet to meet the medical needs of the resident: Sit to stand or sling type mechanical lifts are not listed in this section. On 12/4/24 at 2:00PM V3, Assistant Director of Nursing provided a list of 18 residents who currently use mechanical lifts for mobility. V3 verified all of these residents use mechanical lifts for mobility. V3 verified it is possible that all residents who live at the facility could have to utilize a mechanical lift in the event of a fall. 2. The facility assessment dated [DATE] Section B. Medications does not list Narcotic medications or opioids. R38's Medication…

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.

Failures at this level require more than one deficient practice statement. A. Based on observation, record review and interview, the facility failed to maintain infection prevention procedures to provide a sanitary laundry service. This failure has the potential to affect all 90 residents residing in the facility. Findings include: On 12/02/24 at 02:18 PM V9 identifies self as dayshift laundry aide. V9 entered the soiled linen holding room, applied gloves to the hands, no gown or other PPE (Personal Protective Equipment) was applied and sorted the soiled laundry into containers for personal linens, facility white linens, slings and facility incontinence linens. V9 removed the soiled linen from the collection barrels. Soiled linen included personal linen, soiled incontinence bed pads, soiled towels and washcloths, and soiled bed linen. V9 was observed leaning over soiled linen carts, V9's personal clothing was touching soiled linen collection barrels and the soiled linen including soiled bed pads, bed linens and soiled personal clothing. V9 states V9 sorts the laundry 3-4 times…

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

Based on interview, and record review, the facility failed to document education, offering the COVID-19 Vaccine, and the consent and/or declination of COVID-19 vaccines for staff. This failure has the potential to affect all 90 residents residing in the facility. Findings include: The facility census sheet dated 12/2/24 documents there are 90 residents who reside at the facility. On 12/3/24 at 10:00 AM employee V30 Licensed Practical Nurse (LPN), V32 Certified Nursing Assistant (CNA), V33 CNA, V34 CNA, V35 CNA, V36 CNA, V37 Resident Aide, V38 LPN, V40 LPN files were reviewed for documented evidence of education, offering of the COVID-19 Vaccine to staff, and the consent and/or declination of COVID-19 vaccines. None was obtained from the files. On 12/3/24 at 11:00 AM V13, Human Resource Manager, stated V13 was new to the human resources position. V13 stated V13 is unable to locate any documented evidence of education, offering of the COVID-19 Vaccine to staff, and the consent and/or declination of COVID-19 vaccines for staff. On 12/3/24 at 11:12 AM V1 stated the staff is unable 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 implement accurate complete care plans to include fall prevention, pressure ulcer prevention, oxygen treatment, communication methods and medications for four of four residents (R15, R40, R54, R231) reviewed for care plans in a sample list of 43. Findings Include: 1.) R15's face sheet dated 12/04/24 documents medical diagnoses including Left Femur Fracture, Acute Kidney Failure, Pressure Ulcer of Buttock Stage 2, Major Depressive Disorder, and Anxiety. R15's Physician Wound Notes dated 10/23/24, 10/31/24, 11/6/24, 11/13/24, and 11/20/24 document unstageable, stage 4 and stage 3 pressure ulcers for R15. On 12/3/24 at 11:04 AM R15 had dressings to the right shin, left heel, and left great toe. R15's current Care Plan with admission date of 6/18/24 does not document any pressure ulcers or current interventions. R15's Progress Note dated 8/15/2024 at 09:08PM documents R15 self-propelled into R15's room and placed the call light on and R15 was notified that the CNA (certified nurse assistant) was with another…

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 reviews, the facility failed to assess the residents for eligibility, and ensure residents were offered and administered the pneumococcal and influenza vaccines. This failure affects four (R14, R43, R26, R54) of five residents reviewed for immunization in the sample list of 43. Findings include: 1. R14 Continuity of Care Document dated 12/04/2024 at 1:00 PM documents an admission date of 05/27/2020. R14 medical record review does not include an Influenza Education and consent/declination form for the Influenza vaccine. R14 medical record contains an undated Pneumococcal Education and consent/declination form for the Pneumococcal vaccine. R14 face sheet dated 12/05/2024 at 10:02 AM documents administration of the Influenza Vaccine on 11/7/2023. R14 Medication Administration Record (MAR) dated 12/05/2024 at 10:03 AM for 10/1/24 thru 10/31/24 does not document the administration of the influenza/pneumococcal vaccines. 2. R43 Face Sheet dated 12/04/2024 at 01:07 PM documents an admission date of 02/25/2020. R43 medical record review contains an Influenza…

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 submit the Minimum Data Set (MDS ) in a timely manner for one resident (R74) of 18 residents reviewed for MDS in a sample list of 43. Findings Include: The facility's Final Validation Report printed 12/4/24 at 8:52AM documents R74's MDS target Date 5/2/24 Care Plan Late. Care Areas Assessment (CAA) is more than 13 days after entry date. R74's MDS target Date 7/24/24 Assessment completed Late. Care Areas Assessment (CAA) is more than 14 days after assessment reference date. On 12/04/24 at 8:56 AM V16 Care Plan Coordinator and V17, Corporate Care Plan Consultant verified Assessment/Care Plan for R74 dated 5/2/24 and 7/24/24 were late. The facility's Care Plan Policy revised 11/28/19 states The comprehensive Care Plan will be developed within seven days after the completion of the comprehensive MDS assessment as outlined in the resident assessment (RAI) guidelines.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete resident comprehensive assessments. This failure affects one resident (R14) of 3 residents reviewed for accuracy of assessments on the sample list of 43. Findings include: R14's Minimum Data Set (MDS) dated [DATE] Section N0415 documents R14 as taking an anticoagulant. R14's Clinical Physician Orders do not document an order for an anticoagulant in the medical record. On 12/3/24 at 2:15 PM V16 stated R14 was not on an anticoagulant and the MDS was coded wrongly. V16 stated V16 would need to modify and submit a correct MDS.

Based on interview, and record review, the facility failed to refer residents with newly diagnosed serious mental disorders for a level II PASARR (Pre-admission Screening and Resident Review) resident review upon a significant change in status assessment for two of two residents (R6, R14) reviewed for level II screening in the sample list of 43. Findings include: R6's Continuity of Care Document dated 12/04/2024 at 12:59 PM documents an admission date of 08/03/2020. R6's Interagency Certification of Screening Results dated 8/13/2020 does not document there is a reasonable basis to suspect a mental illness for R6. R6's Continuity of Care Document dated 12/04/2024 at 12:59 PM documents a diagnosis of Unspecified psychosis not due to a substance or known physiological condition was added for R6 on 04/04/2024. R6's Continuity of Care Document dated 12/04/2024 at 12:59 PM documents a physician order for the antipsychotic medication Seroquel (quetiapine) 25 mg tablet at bedtime. R14's Continuity of Care Document dated 12/04/2024 at 1:00 PM documents an admission date of 05/27/2020. R14'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 revise care plans following falls with injury and new pressure ulcers for three of four residents (R26, R15, R181) reviewed for care plans in of a sample of 43. Findings Include: The facility's Care Plan Policy revised 6/1/22 states It is the policy of this facility to develop and implement a Base Line Care Plan, a comprehensive person-centered care plan and conduct care plan meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental, and psychological needs that are identified in the resident's comprehensive assessment. 1. R181's Treatment Administration Record (TAR) for December 2024 includes a treatment order for Coccyx wound -apply calcium alginate and silicone bordered foam dressing daily. R181's Initial Wound Evaluation and Management Summary dated 11/27/24 documents (R181) has a stage II Pressure Ulcer on the coccyx measuring 1.2 x 0.7 x 0.1 Centimeters of greater that one days…

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

Based on observation, interview and record review the facility failed to administer insulin per manufacturer's directions and according to standards of practice for three residents (R25,R45, R47) of four residents reviewed for insulin administration in a sample list of 43 residents. Findings Include: 1. R25's Medication Administration Record (MAR) for December 2024 includes an active physician's order for Novolog (insulin) Flexpen U100. Subcutaneously per sliding scale before meals. The manufacturer's package insert for Novolog Flexpen U-100 documents Novolog starts acting fast. Eat a meal within 5 to 10 minutes after taking it. On 12/4/24 at 11:00AM V30 Licensed Practical Nurse (LPN) stated I have given all my insulin for 100 hall for lunch today. When asked when lunch would be served V30 stated about 12:00 Noon. R25's Medication Administration Record for December 2024 documents R25's insulin was administered at 11:04AM on 12/4/24. 2. R45's Medication Administration Record (MAR) for December 2024 includes an active physician's order for Admelog SoloStar U-100 Insulin (insulin…

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 an effective communication program for one resident (R40) of 18 residents reviewed for communication in a sample list of 43. Findings Include: R40's Continuity of Care Document printed 12/5/24 includes the following diagnoses: Amyotropic Lateral Sclerosis, Dysphasia, and Anxiety Disorder. On 12/02/24 at 2:18 PM R40 was in his room in a custom fitted wheelchair. R40 spoke very softly and deliberately but given time could be understood. R40 stated They don't take time to listen to me. They assume I can't talk to them, but I can. I have Amyotropic Lateral Sclerosis (Lou GehrigsDisease). I am 44 and I would like to be talked to. Sometimes I feel like I am not here. R40's Minimum Data Set (MDS) dated [DATE] documents R40 is cognitively intact and sometimes understood. On 12/3/24 at 9:00AM V10, Licensed Practical Nurse (LPN) stated I am agency, but I come to this facility a lot. (R40) is alert and oriented and can speak, but not very…

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.

Failures at this level require more than one deficient practice statement. A. Based on interview and record review, the facility failed to transcribe and implement physician orders to start a medication for one of one resident (R72) reviewed for medication orders on the sample list of 41. This failure resulted in a delay of medication administration for R72. Findings include: R72 's Progress Note dated 11/14/2024 at 02:10 PM written by V41 Registered Nurse documents the primary care physician was at the facility. The Note documents a new order for Colace QD (Daily) for chronic constipation. On 12/5/24 at 10:43 AM, R72's Clinical Physician Orders do not contain the physician order to administer Colace (Laxative) daily. On 12/5/24 at 10:46 AM, R72's November 2024 Medication Administration Record does not document the administration of Colace. On 12/5/24 at 10:44 AM R72's December 2024 Medication Administration Record does not document the administration of Colace. As of 12/5/24 R72 has missed 21 doses of the medication. On 12/4/24 at 11:27 AM V2 Director of Nurses stated all nurses…

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 assess, implement interventions and physician ordered treatments to prevent the development/worsening of pressure ulcers for two (R181, R15) of three residents reviewed for pressure ulcers in a sample list of 43 residents Findings Include: 1.) R181's Minimum Data Set (MDS) dated [DATE] documents R181 was cognitively intact and not at risk for pressure ulcers had any pressure ulcers. R181's Continuity of Care Document dated 12/5/24 includes the following diagnoses: Displaced Fracture Right Femur (10/30/24), Generalized Anxiety Disorder, Muscle Wasting/Atrophy, Parkinson's Disease, and Chronic Congestive Heart Failure. R181's Initial Wound Evaluation and Management Summary dated 11/27/24 documents (R181) has a stage II Pressure Ulcer on the coccyx measuring 1.2x0.7x0.1 Centimeters of greater that one days duration. R181's Treatment Administration Record (TAR) for December 2024 includes a treatment order for Coccyx wound -apply calcium…

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 date, label humidifier bottles and oxygen tubing when changed for three of three residents (R11, R20, R231) reviewed for respiratory services in the sample list of 43. Findings include: The facility's Oxygen Policy and Procedure with a revision date of 03/16/17 documents, Oxygen set-up (cannula/mask, tubing) must be exchanged every 7days. Documentation: Date, time, flow rate, frequency, and results of oxygen therapy Medical Record. 1.) R20's Medication Administration Record dated 12/1/2024 - 12/2/2024 documents O2 at 2 liters per nasal cannula continuous for SOB (Shortness of Breath). This Medication Administration Record dated 12/1/2024 - 12/2/2024 documents to Change O2 (oxygen( nebulizer tubing Q (every) week. This Medication Administration Record dated 12/1/2024 - 12/2/2024 documents V40 changed the tubing and humidifier bottle on 12/1/24. On 12/2/24 at 11:18 AM, R20's oxygen concentrator was running via a nasal cannula. There is no date of the humidifier bottle or tubing to indicate when it was…

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

Based on interview and record review the facility failed to monitor one resident (R38) receiving opioid medication for bowel function for one resident reviewed for opioid medication in a sample list of 43. Finding include: R38's Medication Administration Record (MAR) for December 2024 documents R38 has a current order for hydrocodone-acetaminophen tablet; 5-325 mg; amt: 1tablet; oral Every 8 Hours - PRN (as needed). It is documented on this MAR R38 received this as needed medication four times between 11/29/24 and 12/4/24. There is no documentation to support R38's bowel function is being monitored. R38's Care Plan reviewed 10/8/24 does not include interventions to monitor bowel movements for use of an opioid medication. R38's Progress Note dated 10/9/24 at 8:14 Am documents R38 reported (R38) had not had a bowel movement in three days On12/4/24 at 2:00PM V2, Director of Nursing verified the facility has no system in place for monitoring of bowel function in residents who use narcotic medications but if a resident doesn't have a bowel movement is a few days it would be charted in…

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

Based on interview and record review the facility failed to obtain consent, assess/monitor residents receiving psychotropic medications and failed to document attempts to utilize nonpharmalogical interventions for two residents (R15, R38) reviewed for psychotropic medication in a sample list of 43. Findings include: The facility's Pharmacological Drug Usage Procedure revised 10/18/17 states Purpose: 1. To provide appropriate assessment and monitoring of residents receiving these (psychotropic) medications. 2. To ensure residents receive gradual dosage reductions and behavioral interventions in an effort to discontinue these medications and minimize adverse consequences. Procedure: 2. Psychopharmacological medication usage must be reassessed at least every 90 days and include rationale for continuation the medication. 1.) R38's active physician's orders printed 12/5/24 include the following orders for psychotropic medications Clonazepam (antianxiety) 1 mg (milligrams) TID (three times daily) Trazadone (Antidepressant) 50 mg daily, Paxil (Antidepressant) 20 mg daily and Melatonin…

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 timeliness of laboratory services were completed as ordered by a physician for one (R28) of one resident reviewed for laboratory services on the sample list of 43. Findings include: R28's undated face sheet documents a diagnosis of type two diabetes mellitus. R28's December 2024 Physician Orders documents and order for R28 to have an A1C (blood test to check ongoing sugar levels) was to be drawn on 2/3/24 and 8/3/24. R28's laboratory results dated [DATE] document results for an A1C level for 9/13/2023 and 10/16/24. R28's medical record did not contain any results for an A1C level on 2/3/24 and 8/3/24. On 12/4/24 at 1:00 PM, V31 Director of Therapy stated R28's A1C level has only been drawn once this year which was on 10/16/24. V31 stated they were unable to find labs for February 2024 and August 2024. On 12/4/24 at 1:30 PM, V2 Director of Nursing stated the floor nurses ensure the labs are being completed as ordered. V2 stated the only A1C…

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 bed bugs and room change to a resident representative for one (R1) of five residents reviewed for bed bugs in the sample list of five. Findings include: The facility's Transfer of a Resident policy dated 1/11/23 documents Upon need for a room transfer within the facility, staff shall meet and discuss the reasons for transfer. The Social Service Director shall discuss the potential room change with the resident and resident's representative. Form NH-#341 Room/Roommate Change Notification shall be utilized should either party request notification in writing. Transfer of the resident and belongings shall be completed as soon as possible and documented by Social Services. The facility's Change in a Resident's Condition dated December 2002 documents the resident's representative will be notified when there are changes in the resident's physical, mental, or psychosocial status. The (Pest Control Company) Proof of Service dated 11/10/24…

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 ensure medical records were complete and accurate for two (R1, R2) of five residents reviewed for bed bugs. Findings include: The (Pest Control Company) Proof of Service dated 11/10/24 documents (R1's/R2's former room) was treated for bed bugs with an insecticide. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment. R1's ongoing Census documents R1 changed rooms on 11/12/24. There is no documentation in R1's medical record that bed bugs were found in R1's room. R2's MDS dated [DATE] documents R2 as cognitively intact. R2's ongoing Census documents R2 changed rooms on 11/12/24. There is no documentation in R2's medical record that bed bugs were found in R2's room. On 11/18/24 at 9:46 AM there were no residents residing in R1's/R2's former room. At 9:58 AM R1's current room was observed. On 11/28/24 at 10:38 AM R2 was in R2's room. R2 stated R2 recently moved rooms because the facility told R2 that bugs were found 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 that facility failed to revise comprehensive care plans appropriately for five of ten residents (R1, R3, R4, R5, R9) reviewed for care plan revision out of a sample list of ten. Findings include: The facilities policy Care Plan Policy dated 6/1/22 documents, the facility will revise comprehensive care plan when there is a change in resident goals, or physical, mental, or psychosocial functioning, which was not otherwise identified in the baseline care plan. 1.) R1's Care Plan documents that R1 was admitted to the facility on [DATE] and documents a problem start date of 7/2/24 regarding R1 displaying physical and verbal behaviors directed towards staff. The only interventions for this problem were to approach R1 slowly and explain tasks prior to initiating. R1's Nurse's Notes dated 9/11/24 at 8:23 PM documents that R1 tried to transfer another resident from her wheelchair to another chair. That resident had to be lowered to the floor and R1 was sent out to 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 timely report an allegation of resident to resident abuse to the state survey agency for two of four residents (R1, R2) reviewed for abuse in the sample list of 10. Findings include: The facility's Abuse Prohibition and Reporting policy with a revised date of 11/28/19 documents that employees should immediately report alleged abuse to the Administrator. If the matter involves alleged abuse, the Administrator or designee shall provide the Illinois Department of Public Health with initial notice of the alleged abuse as soon as possible, but not more than 2 hours after the matter becomes known. R1's Nurse's Note dated 9/29/24 at 4:33 AM by V8 Licensed Practical Nurse documents V8 was at the nurse's station and heard someone yell help me. V8 documents that she went to R2's room and saw R1 standing over her as R2 was laying on the floor. R1 became aggressive when V8 asked him to leave the room. V8 documents that Emergency Medical Services (EMS) and the police were called. V8 documented that the police arrived at 1:48 AM and EMS…

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 develop and implement a baseline care plan for one of ten (R5) residents reviewed for comprehensive care plan out of a sample list of ten. Findings include: The facilities Care Plan Policy dated 6/1/22 documents the facility will develop a baseline care plan within 48 hours of a resident's admission. R5's electronic face sheet dated 10/1/24 documents R5 was admitted to facility on 9/23/24. On 9/30/24 at 2:40 PM, V1 (Administrator) stated she was unable to find a baseline care plan. Electronic care plan record does not document a comprehensive care plan on 9/30/24. On 9/30/24 at 2:30 PM, V7 (Certified Nursing Assistant) stated R5 is NPO (nothing by mouth) and an one assist for transfers. V7 stated R5 will often get up alone without asking for assistance or pressing call light. V7 stated R5 likes to take his clothes off often and pulls at gastrostomy tube (G-Tube). V7 stated R5 prefers to sleep in wheelchair or recliner chair. R5 is on contact isolation for Extended Spectrum Beta-Lactamases (ESBL) in urine.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to document/monitor/track resident behaviors and failed to develop/implement non pharmacological behavioral interventions for one of four residents (R1) reviewed for abuse in the sample list of 10. Findings include: The facility's Behavior Emergencies policy with a revised date of 6/1/22 documents the purpose of the policy is to ensure the safety of al resident by evaluating resident on admission and when behavior emergencies occur. This policy also documents that the nursing staff will put into action intervention techniques agreed upon after consulting with physician's. The policy documents that an evaluation by a psychiatrist (if ordered by a physician) will be completed and nursing staff will record a detailed report of behaviors. This policy documents the inter-disciplinary care plan team will meet to discuss the resident involved and review and modify the care plan as appropriate. R1's undated Care Plan documents R1 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to obtain a stop date for a PRN (as needed) antipsychotic medication, failed to complete initial and quarterly psychotropic medication assessments, failed to document behaviors to warrant the use of an antipsychotic medication, failed to develop care plan with non-pharmacological interventions and failed to obtain psychotropic medication consents for two of three residents (R1, R9) reviewed for psychotropic medications in the sample list of 10. Findings include: The facilities policy Psychopharmacological Drug usage procedure dated 10/18/17 documents Residents will not receive Psychotropic drugs unless the medication is necessary to treat a diagnosed specific condition. PRN orders for psych drugs are limited to 14 days unless the MD extends another 14 days. Rationale needs documented in Residents medical record for PRN order. AIMS testing must be done on all residents receiving anti-psychotic drugs at start of therapy and at least every 6…

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 insulin was administered as ordered and failed to monitor blood glucose levels as ordered resulting in a significant medication error for one of three residents (R8) reviewed for medications in the sample list of 10. Findings include: The facility's Medication Administration policy with a revised date of February 2004 documents the objective is to provide medications deemed necessary for a diagnosed condition. This policy also documents, All medications must be administered to the resident in the manner and method prescribed by the physician. R8's undated diagnosis list includes diagnoses of Acute Kidney Failure, Type 2 Diabetes Mellitus and Chronic Kidney Disease Stage 3. R8's Medication Administration Record (MAR) dated 7/1/24-7/30/24 documents orders for Insulin Lispro 100 units/ml (milliliters) per sliding scale after meals for Type 2 Diabetes Mellitus with a start date of 6/18/24. During July R8 received anywhere from 2 units to 8 units of insulin per meal. R8's MAR dated 7/1/24-7/30/24 documents an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to answer call lights and care requests timely for four (R1, R2, R3, R8) of eight residents reviewed for call lights in the sample list of eight. Findings include: The facility's Call Light policy dated January 2004 documents to answer call lights promptly, respond to resident's request, and promptly return to the room if you need to obtain assistance or supplies. The facility's Resident Council Meeting Minutes dated 4/1/24 documents residents voiced concerns that second shift Certified Nursing Assistants (CNAs) have rude attitudes when answering the call light, call lights are turned off and staff say they'll return, and CNAs are telling the residents they are short staffed and need to be patient. These minutes document that on third shift residents wait over 20 minutes for call light response. The facility's Resident Council Meeting Minutes dated 5/6/24 document residents voiced concerns that agency CNAs turn call lights off and walk out 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 ensure the use of a departure alert system was being used in the treatment of medical symptoms and not for staff convenience. This failure affects one (R1) of three reviewed for supervision on the sample list of six. Findings include: R1's Face Sheet (current) documents R1 was admitted to the facility on [DATE] with diagnoses including: Transient Cerebral Ischemic Attack, Difficulty in Walking, and Muscle Wasting/Atrophy. R1's Comprehensive Assessment (MDS) dated [DATE] documents R1 is severely cognitively impaired. On 5/14/24 at 10:22am, V12 (Activity aide) stated V3 (Activity aide) got a text that R1 was across the street. V12 stated V12 and V3 ran across the street and R1 was across the road by the fence walking towards the water tower. V12 stated R1 told her she was doing a lap around when we found her. V12 stated, I have seen her walk down to the end of sidewalk and walk back up while I was outside. I was told on 5/10/24 after the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately complete R1's comprehensive assessment. This failure affects one (R1) of three residents reviewed for accuracy of assessments on the sample list of 6. Findings include: R1 was observed intermittently throughout the survey on 5/14/24 and 5/15/24 utilizing a four-wheeled walker for ambulation. R1's Face Sheet (current) documents R1 was admitted to the facility on [DATE] with diagnoses including: Transient Cerebral Ischemic Attack, Difficulty in Walking, and Muscle Wasting/Atrophy. R1's Care Plan dated 5/1/24 documents the following entries dated 5/8/24: uses a walker with one assist. R1's Comprehensive Assessment (MDS) dated [DATE], Section GG Functional Abilities and Goals, documents R1 uses a motorized wheelchair and/or scooter. On 5/14/24 at 10:30am, V5 Regional Nurse Consultant stated the facility does not currently have an MDS Coordinator. On 5/15/24 at 9:10am, V14 Certified Occupational Therapist Assistant stated R1 uses 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 develop and implement a person centered comprehensive care plan for elopement (R2 and R3) for two of three residents reviewed for elopement in the sample list of 6. Findings include: The facility Risk for Elopement list dated 5/13/24, documents R2 and R3 as elopement risks. R2's Care Plan dated 5/1/24 does not include elopement. R3's Care Plan dated 5/1/24 does not include elopement. On 5/14/24 at 10:30 am V5 Regional Nurse Consultant states that care plans are not being updated because they don't have a Care Plan Coordinator or MDS Coordinator. V5 confirms that R2 and R3 do not have an Elopement Risk care plan and the departure alert system is not documented on R1's comprehensive care plan. The Missing Resident Policy dated 2/25/19 Residents at risk for wandering shall be assessed and addressed on the care plan. The facility Care Plan Policy revised on 6/1/22 states: It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings 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.

Based on interview and record review, the facility failed to notify a resident's (R1) Health Care Power of Attorney of the delayed collection and results of an ordered urinalysis with subsequent bacteria growth, resulting in antibiotic treatment. R1 is one of three residents reviewed for family notifications of treatments and changes in conditions on the sample of eight. Findings include: R1's Physician Order Sheet dated February includes an order dated 2/27/24 for a UA/C&S (Urinalysis with Culture and Sensitivity). R1's Progress Notes dated on 3/2/24 and on 3/4/24 document urine was collected for the above order. The 3/2/24 urine sample was not sent and the sample of 3/4/24 was sent to the laboratory for testing (6 days after the order to collect one). R1's Laboratory report dated 3/4/24 documents R1's urine as being positive and a culture and sensitivity was completed. On 3/6/24 per Laboratory reports, R1's urine grew the bacterium of Escherichia coli with greater than 100,000 colony forming units per milliliter of urine in the sample. On 3/7/24 an order for Cefdinir (antibiotic)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a routine bath and/or shower to one (R1) of three residents reviewed for bathing in the sample of eight. Findings include: R1's Minimum Data Set, dated [DATE] documents the following: R1 is moderately cognitively impaired, incontinent of both urine and bowel and needs substantial assist with activities of daily living. R1's Care Plan (current) directs staff to assist with showers on Wednesday and Saturdays. R1's Shower data sheet documents R1 receiving a shower on 3/9/24 and not getting another shower until 3/17/24 (8 days later). There were no hospitalizations during this time per the Facility Census Sheet. On 3/26/24 at 10:00 am, R1 stated he doesn't remember when R1's showers are given, but R1's family have told R1 that R1 smells at times. On 3/26/24 at 11:00 am, V2 Director of Nursing confirmed the facility did not have documentation that R1 received a shower after 3/9/24 until a shower was given on 3/17/24.

Based on interview and record review, the facility failed to collect and send an ordered urine sample for a resident (R1) with a known history of Urinary Tract Infections in a timely manner. Thus, delaying treatment for a positive urinalysis and culture. R1 is one of three residents reviewed for Urinary Tract Infections and treatment in the sample of eight. Findings include: R1's Face Sheet dated January 2024 (on admit) includes the following diagnoses: Benign Prostatic Hypertrophy, Urinary Tract Infection, Difficulty Walking, Muscle Wasting and Chronic Kidney Disease. R1's Physician Order Sheet dated February includes an order dated 2/27/24 for a UA/C&S (Urinalysis with Culture and Sensitivity). R1's Progress Notes document the following: 02/27/2024 at 12:55 pm - Communication faxed to (V9 Primary Care Physician) notifying of resident (R1's) noticeable decline over the last couple of days. Awaiting new orders. 02/27/2024 at 5:16 pm - (V9) faxed back the following orders: obtain CBC (Complete Blood Count), CMP (Comprehensive Metabolic Profile), TSH (Thyroid Stimulating Hormone), UA…

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 follow medical doctor's medication administration orders for four residents (R5, R6, R7, R8) of four residents reviewed for medication administration/distribution in the sample list of four. Findings include: R5's undated Face Sheet documents R5's diagnoses as: Major Depressive Disorder, Pain, unspecified, unspecified Dementia, and Diabetes Mellitus with unspecified complications. R5's Physician Orders dated 1/1/24 to 1/31/24, document orders for Cymbalta (Antidepressant/Nerve Pain) 60 milligrams (mg) by mouth twice a day, Gabapentin (Antidepressant/Nerve Pain) 600 mg 0.5 tablet by mouth twice a day, Memantine (Dementia/Memory Loss) 10 mg by mouth twice a day, Metformin (Antidiabetic) 500 mg by mouth twice a day, and Naproxen (Anti-inflammatory/Pain) delayed release/enteric coated 500 mg by mouth twice a day. R5's Medication Administration Record (MAR) dated 1/29/24, documents the 7:00 AM - 10:00 AM doses of all the medications as missed/not given. R6's undated Face Sheet documents R6's diagnoses as: Essential (primary)…

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

Based on interview and record review, the facility failed to administer significant medications (which can jeopardize resident's health and safety) for one of four residents (R8) reviewed for significant medications in the sample list of four. Findings include: R8's undated Face Sheet documents R8's diagnoses as: Cerebral Infarction, unspecified and Chronic Atrial Fibrillation, unspecified. R8's MAR dated 1/1/24 - 1/31/24, documents Amiodarone (chronic atrial fibrillation) 200 mg once a day, not administered on 1/28/24 or 1/29/24 documenting drug unavailable on both days. This same POS documents Lasix (heart failure) 20 mg once a day, not administered on 1/15/24, 1/16/24, 1/17/24, 1/28/24, and 1/29/24, documenting drug unavailable for all five days. On 2/1/24 at 10:30 AM, V1 Administrator stated V1 was unaware of medications being given late and medications not being available in the convenience box. On 2/1/24 at 3:16 PM, V7 Corporate Nurse, stated if medications have not been taken in a few days the doctor should notified. The facility's Medication Errors and Drug Reactions Policy…

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

Based on interview and record review, the facility failed to accurately document medication distribution times for three residents (R4, R6, R7) of four residents reviewed for accurate medication administration documentation in the sample list of four. Findings include: R4's Medication Administration Record (MAR) dated 1/1/24 to 1/31/24, documents on 1/29/24, R4 received 7:00 AM-10:00 AM medications at 3:54 PM. These medications include: Cholecalciferol, Lasix, Lisinopril, Lorazepam, Zoloft, and Seroquel. R6's MAR dated 1/2/24 to 1/31/24, documents on 1/29/24, R6 received 7:00 AM-10:00 AM medications at various times. These medications include: Aspirin 3:50 PM; Cholecalciferol 3:50 PM; Diclofenac Sodium, 2 doses at 2:39 PM; Folic Acid 3:50 PM; Furosemide (twice a day) 3:50 PM; Leflunomide 3:50 PM; Metoprolol Succinate 3:50 PM; Potassium Chloride (twice a day) 3:50 PM; and Prilosec 3:50 PM. R7's MAR dated 1/2/24 to 1/31/24, documents on 1/29/24, R7 received 7:00 AM-10:00 AM medications at 4:01 PM and/or given two doses at one time. These medications include: Amlodipine; Aspirin;…

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 Registered Nurse coverage for at least 8 consecutive hours a day, 7 days a week for a total of 3 days in the 14 days reviewed. This failure has the potential to affect all 76 residents residing in the facility. Findings include: Reviewing the facility's nurse's assignment sheet from December 24, 2023 through January 6, 2024. The facility had 3 days during this schedule which did not document RN time of 8 hours per day. The following days of 12/25/23, 12/26/23 and 12/31/23 were the days the facility did not provide the 8 hours of RN coverage. Licensed Practical Nurses worked the 3 days the RNs were not present. V2 (Regional Corporate Nurse) confirmed on 1/10/24 at 10:30 AM Yes those 3 days we did not have an RN scheduled to work. The facility's Long Term Care Facility Application for Medicare and Medicaid dated 1/9/24 documents 76 residents reside in the facility.

Based on interview and record review, the facility failed to develop a thorough and complete Quality Assessment & Assurance (QAA) of Policies and Procedures and a Quality Assurance Performance Improvement (QAPI) Program. The facility also failed to implement the QAA and QAPI Programs by failing to identify quality deficiencies, develop and implement appropriate plans of action to correct such deficiencies, and conduct distinct Performance Improvement Projects (PIPS). This failure has the potential to affect all 76 residents in the facility. Findings include: On 1/10/24 at 9:59am, V1 (Administrator) stated the facility does not have a more comprehensive QAPI policy. V1 confirmed the QAA Committee has not been implementing the QAA Policies and Procedures and has not been implementing a complete QAPI Program. The Quality Assurance Performance Improvement Policy dated 6/1/22 documents the facility shall implement an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. A QAPI plan shall be developed through the use 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 interview and record review, the facility failed to ensure required personnel attended the Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 76 residents in the facility. Findings include: On 1/10/24 at 9:59am, V1 (Administrator) provided QAA meeting attendance signature sheets for the previous year's QAA meetings dated 1/26/23, 4/27/23, 7/27/23 and 10/26/23. On 1/10/24 at 10:18am, V2 (Regional Nurse) confirmed there were no identifiers noting the Director of Nursing or Infection Preventionist on the QAA meeting attendance signature sheets for 1/26/23, 4/27/23, and 7/27/23. V1 and V2 were unable to identify the Director of Nursing and Infection Preventionist as V1 began employment at the facility on 9/5/23 and V2 was unsure who held those positions during those times. The January 2023 QAA meeting attendance signature sheet does not document the facility Director of Nursing was present for the meeting. The April 2023 QAA meeting attendance signature sheet does not document the Infection Preventionist and V9 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 observation, interview, and record review, the facility failed to respond to residents' requests for toileting assistance in a timely manner, resulting in residents experiencing episodes of incontinence, and failed to properly perform urinary catheter care. These failures affect four residents (R10, R11, R26, R67) out of four reviewed for incontinence and urinary catheter on the sample list of 31. Findings include: 1. On 1/10/24 at 12:57 PM, at the resident group interview, R10 stated, I have had to wait to go to the bathroom, the CNAs (Certified Nursing Assistants) say they are too busy because they are short staffed. I also used to need two people to help me but now I can go with only one, but I don't think that has been communicated very well and I think they don't want to come help me because they still think I need two people. R10 further stated, I have had some incontinence because of having to wait so long. R10's Minimum Data Set (MDS) dated [DATE] documents R10 received a score of 15 out of 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 observation, interview, and record review, the facility failed to ensure their medication error rate was less than 5% during medication pass on 1/10/24. There were 26 opportunities, and total medication errors were 4. This gives the facility a 15.38% medication error rate. This failure affects four residents (R5, R26, R60, R229) out of 14 on the sample list of 31. Findings include: 1. On 1/10/24 at 3:13 PM, V5 (Registered Nurse) administered R26 Metoprolol Tartrate 25 milligram, 0.25 tablet (1/4 tablet) to equal 6.25 milligrams. R26's Physician Order Sheet (POS) documents Metoprolol Tartrate 25 mg 1 tablet BID. 2. On 1/10/24 at 3:47 PM V11 (Licensed Practical Nurse/LPN) passed medications to R5 and did not give the medication ordered for Pataday eye drops 1 drop to both eyes. V11 stated at 3:47 PM We do not have this drug in our cart to give R5. No alternative medication was given to R5. 3. V11 passed medications to R229 and failed to serve the medication with food as directed on the medication card and the physician's orders. On 1/10/24 at 3:49 PM R229 received 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 Level 2 PASARR (Pre-admission Screening and Record Review) for residents receiving a mental illness diagnosis during their residency at the facility. This failure affects three residents (R14, R35, R43) out of six reviewed for PASARR on the sample list of 31. Findings include: 1. R14's current Face Sheet dated 1/10/24 documents R14 was originally admitted to the facility 8/11/21. R14's original OBRA (Omnibus Reconciliation Act) Pre-admission Screen dated 7/28/21 documents there was no reasonable basis to suspect mental illness or developmental disability for R14. R14's current Face Sheet dated 1/10/24 documents R14 received a mental illness diagnosis 'Psychotic Disorder with Delusions Due to a Known Physiological Condition' on 10/7/21. R14's current Physician Order Sheet dated 1/10/24 documents R14 receives the anti-psychotic medication Quetiapine 150 milligrams (mg) each bedtime and 100 mg each morning, prescribed for R14's mental illness diagnosis of Psychotic Disorder with Delusions Due to a Known Physiological…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline Care Plan within 48 hours of resident's admission for one resident (R376) of one resident reviewed for Care Plans in the sample list of 31. Findings include: R376's undated Face Sheet documents R376's medical diagnoses as: Diabetes Mellitus Due to Underlying Condition without Complications, Pain in Unspecified Hip, Essential (primary) Hypertension, Chronic Obstructive Pulmonary Disease, Chronic Atrial Fibrillation, Pulmonary Hypertension, Calculus of Kidney, Low Back Pain, and Constipation. This same Face Sheet documents R376 was admitted to the facility on [DATE] at 1:30 PM. There was no baseline care plan in R376's medical record. On 1/10/24 at 2:50 PM, V2 (Regional Nurse) confirmed there was not a baseline care plan for R376 and V2 just did it. The facility's Care Plan Policy dated Revised 6/1/22, documents the baseline Care Plan will be completed within 48 hours of a resident's admission by gathering information from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a discharge summary for one resident (R73) who was discharged to another nursing facility. R73 is one of one resident reviewed for discharge in a sample list of 31. R73's closed Electronic Medical Record documents R73 initiated a discharge to another nursing facility. R73's historical Physician Order Sheet dated October 2023 documents the facility had received an order for R73 to be transferred to another nursing facility on 10/25/23. R73's care plan dated 9/7/23 does not contain any information concerning preparation for R73 and the impending discharge. The family of R73 came to the facility on [DATE] to transfer R73 to her new facility and the family was not given discharge information for R73 including a medication list or required levels of assistance. R73's closed Electronic Medical Record did not have any discharge summary or recapitulation of stay. Information stated in R73's progress notes was an order was received on 10/25/23 and R73…

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 showers to residents according to their plans of care, physician orders, and preferences. This failure affects two residents (R10, R26) out of four reviewed for activities of daily living on the sample list of 31. Findings include: 1. On 1/10/24 at 12:57 PM, at the resident group interview, R10 stated, The showers are not getting done, the staff say they are too busy, or they are short staffed. R10's Minimum Data Set (MDS) dated [DATE] documents R10 received a score of 15 out of a possible 15 for a Brief Interview for Mental Status (BIMS), rating R10 as cognitively intact. This same MDS documents R10 requires partial to moderate assistance for transfers from chair to shower, and for showering. R10's current Physician Order Sheet and Care Plan, both dated 1/10/24 document R10 is scheduled to receive showers twice weekly on Mondays and Thursdays. R10's documented Shower Sheets dated 11/2/23 through 1/8/24 document R10's showers were…

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 skin risk assessments, wound management daily reports, document weekly wound descriptions/measurements, and complete weekly skin checks for one resident (R67) of two residents reviewed for pressure ulcers in the sample list of 31. Findings include: R67's undated Face Sheet documents R67's diagnoses as: Cerebral Infarction, Muscle Wasting and Atrophy, Need for Assistance with Personal Care, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. R67's Physician orders dated 1/2024, document for staff to conduct weekly skin checks on Wednesdays 7:00 AM - 3:00 PM shift. R67's Treatment Administration Record (TAR) dated 7/1/23-7/31/23, the documentation of R67's weekly skin checks were not documented as being completed on Wednesday 7/5/23, Wednesday 7/12/23, Wednesday 7/19/23; TAR dated 8/1/23-8/31/23, the documentation of R67's weekly skin checks were not documented as being completed on Wednesday 8/16/23, Wednesday 8/23/23, Wednesday 8/30/23; TAR dated 9/1/23-9/30/23, the…

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

Based on observation, interview, and record review, the facility failed to maintain humidification of supplemental oxygen, failed to change oxygen tubing, and failed to document physician orders for oxygen administration. These failures affect one resident (R26) out of one reviewed for oxygen on the sample list of 31. Findings include: On 1/9/24 (Tuesday) at 10:14 AM, R26 was seated in her own room in a wheelchair. R26 was receiving supplemental oxygen from a concentrator at two liters by a nasal cannula. R26's undated oxygen humidifier bottle was completely empty and dry, and the oxygen cannula tubing was not dated. On 1/9/24 at 10:14 AM, R26 stated, I am having trouble breathing this morning. I am all stopped up. I had covid last month and this is day 20 of my breathing troubles. On 1/9/24 at 12:12 PM, V4 (Registered Nurse/RN), stated, We change the humidifier bottles and tubing once a week. On 1/9/24 at 12:12 PM, V5 (RN), stated, We change them once a week on Monday nights. The changes are marked on the MARs (Medication Administration Records). On 1/9/24 at 3:30 PM, R26 was…

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

Based on interview and record review, the facility failed to obtain physician responses, and failed to implement physician responses, for consultant pharmacist recommendations. This failure affects three residents (R14, R34, and R43) out of five reviewed for unnecessary medications on the sample list of 31. Findings include: 1. R14's Medication Regimen Reviews (MRRs) dated 4/20/23, 5/8/23, 6/19/23, 7/18/23, 8/14/23, 9/25/23, and 10/25/23, all documented the same recommendation from V14 (Registered Consultant Pharmacist), This resident has an order for the following inhaled corticosteroid: Trelegy Ellipta. To prevent candidiasis (thrush) caused by the inhaled corticosteroid, ensure the resident rinses their mouth with water (swish and spit) after each inhalation. Please consider adding this to the order on the MAR (Medication Administration Record). None of the 7 monthly Medication Regimen Reviews documented any follow-up with R14's physician, any response from R14's physician, nor any consideration by the facility's nursing staff to implement or decline to implement V14'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 observation, interview, and record review, the facility failed to follow basic infection control procedures during indwelling catheter care for one resident (R67) of one resident in the sample list of 31. Findings include: R67's undated Face Sheet documents R67's diagnoses as: Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Urinary Tract Infection, and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. R67's Physician Order Sheet dated 1/1/24 through 1/10/24, documents indwelling catheter care every shift. R67's Care Plan dated 12/15/23, documents R67 will have indwelling catheter care managed appropriately as evidenced by not exhibiting signs of infection. On 01/10/24 at 1:50 PM, observed indwelling catheter care for R67 by V12 (Certified Nursing Assistant/CNA). V12 wore the same gloves from beginning of indwelling catheter to end of indwelling catheter care without ever changing V12's gloves. On 1/10/24 at 2:10 PM, V11 (Licensed Practical Nurse/Infection Preventionist) stated V12 should have changed gloves any time going…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of four residents (R4, R5) reviewed for abuse in a sample list of 7. Findings include: The October 2023 Physician Order Sheet documents R4's diagnoses are Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance, Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. R4's Minimum Data Set (MDS) dated [DATE] states R4 is severely cognitively impaired and R4 is able to walk independently with supervision of one staff. R4's care plan dated 9/7/23 documents R4 gets herself up and will start walking down the hall and will go in and out of other resident's room. On October 24, 2023 at 10 AM, R4 got up from sitting in her room and entered another resident's room without supervision. R4 then turned around and came out of the room. The October 2023 Physician's Order Sheet documents R5's diagnoses are Unspecified Dementia, Unspecified…

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 quarterly assessments for the risk of skin breakdown for two of three residents (R1, R2) reviewed for pressure sores in total sample of seven residents. Findings include: 1. The Physicians Order Sheet (POS) dated October 2023 lists the following diagnoses for R1: Dementia with Behaviors, Unspecified Displaced Fracture of Surgical Neck of Right Humerus, initial encounter for Open Fracture, and Pressure Ulcer Stage Four. The same POS also documents R1 was placed on hospice. The Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and R1 requires assistance of two staff in all areas of activities of daily living. The quarterly pressure risk assessment for R1 was completed on 2/1/23 and 5/3/23. Both assessments rated R1 as Moderate Risk for pressure ulcers. R1's next quarterly pressure ulcer risk assessment should have been completed 8/3/23. The assessment was not found in R1's medical record. Hospital records document…

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.