Evercare Of Collinsville

Based on interview and record review, the facility failed to complete a medication review for 1 of 1 resident (R8) reviewed for medications in the sample of 67.R8's Note to attending physician/prescriber dated, printed 7/26/2025 documents consider a gradual dose reduction for the following medication Buspirone 10mg daily. R8's Note to attending physician/prescriber fails to document physician review or signature. R8's Note to attending physician/prescriber dated, printed 8/27/25 documents consider a gradual dose reduction for the following medication: Sertraline 100mg daily the sheet fails to document physician review or signature as sheet is blank. R8's physician order dated 12/18/2025 documents Sertraline 100mg daily, Buspirone 10mg daily. R8's face sheet dated 12/17/2025 documents R8 has a diagnosis of paranoid schizophrenia, major depressive disorder and bipolar disorder, current episode manic without psychotic features. On 12/17/2025 at 11:44AM, V2 Director of Nursing (DON) stated by looking at the blank note to attending physician for consideration of medication reduction,…

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 food was served at palatable temperatures for foods for 4 of 4 (R2, R15, R28, R57) people review for meal services in a sample of 67. Findings include:1. The facility's Resident Council Minutes dated October 15, 2025, documents concern with the food being cold and bland.The facility's Resident Council Minutes dated September 17, 2025; documents concern about food overall.The facility's Resident Council Minutes dated August 20, 2025; documents concern about being cold all the time.The facility's Resident Council Minutes dated June 18, 2025, documents concern with food being bland and cold.2. R2's Minimum Data Set, dated [DATE], documents that R2 is cognitively intact.On 12/16/2025 at 11:20 AM R2 stated that the food is horrible. It's cold. R2 stated that sometimes the food is done and sometimes it's not. R2 stated that If you don't have your own food you will starve. R2 stated that the food comes at different times. R2 stated that sometimes it'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, observation, and record review, the facility failed to perform appropriate hand hygiene when assisting resident with feedings, when performing wound care, and then proper disposal of contaminated linen for 4 of 12 residents (R6, R11, R63, R77) reviewed for infection control practices in the sample of 67.Findings include:1. On 12/15/25 at 12:15 PM, during lunch observation, R6 was seen sitting in the dining room getting feeding assistance from V11, Certified Nursing Assistant (CNA). V11 was seen getting up, assisting other residents, walking to the kitchen and leaving R6 at the table by himself, picking up lunch trays and putting on cart, then sitting back with R6 to assist in feeding him again, all with no hand hygiene seen done before, during, or after assistance given. 2. On 12/15/25 at 10:50 AM, R63 had a contact isolation sign on the wall outside her door. V10, CNA, was performing peri-care on R63 with a gown, mask, and gloves on. V10 had thrown all the soiled linen and wet brief soaked…

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 assistance with eating for 2 of 8 residents (R50 and R70) reviewed for assistance with eating in the sample of 67. Findings include: 1. On 12/15/2025 at 12:08PM trays being passed in 2nd floor dining room. The meal consists of pasta with peas and chicken, cooked carrots, white cake with frosting. On 12/15/2025 at 12:13PM R50 sitting sideways in a regular chair at table with tray in front of R50 with plate with pasta, and cooked carrots, separate plate with cake, glass of water covered with plastic, orange drink covered with plastic, mighty shake (unopened)12:25PM R50 has not taken a bite, just looking at food drinks remain covered with plastic, and mighty shake unopened. On 12/15/2025 at 12:35PM R70 1/2 cake eaten, Casserole and carrots not touched. R70 drank 1/2 glass of drink. R70 is not being provided any cueing or encouragement to eat. At 12:37PM R70 dozing at table, knocks spoon off table to floor, then picks up spoon 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 interview, observation, and record review, the facility failed to ensure a medication error rate of less than 5% for 2 of 4 residents (R2, R6) observed during medication pass. Fourteen errors were observed during 38 opportunities for errors during medication administration. This resulted in a medication error rate of 36.84 percent. The findings include:1. R6's admission Record, dated 12/17/25, documents R6 was originally admitted to the facility on [DATE] with diagnosis of Malnutrition, Catatonic Schizophrenia, Anxiety Disorder, Hypertension (HTN), Dyskinesia, Falls, Type 2 Diabetes Mellitus (DM), Major Depressive Disorder, and Pneumonitis.R6's Care Plan, dated 3/3/25, documents R6 has Impaired Coping, has a Self-Care Deficit, Risk for Decreased Cardiac Output, Risk for Impaired Communication, Decreased Cardiac Output, Arrhythmia, Hypertension, Disturbed Sensory Perception: Audible/Visual, Malnutrition. It continues 12/1/25: R6 has a behavior problem related to catatonic schizophrenia, anxiety 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 interview, observation, and record review, the facility failed to provide hand hygiene while performing resident care for 3 of 4 residents (R2, R3, R8) reviewed for infection control in the sample of 9.The findings include:1. R2's admission Record, dated 11/18/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Malnutrition, Schizophrenia, Anxiety disorder, Hypertension (HTN), Deep Vein Thrombosis (DVT), Dyskinesia, Falls, Type 2 Diabetes Mellitus (DM), and Major depressive disorder. R2's Care Plan, dated 3/3/25, documents R2 has functional bladder incontinence related to catatonic schizophrenia. Interventions: Clean peri-area with each incontinence episode, ensure the resident has unobstructed path to the bathroom, limit fluids 2-3 hours prior to bedtime, monitor and document intake and output as per facility policy, monitor/document for signs/symptoms UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to maintain a homelike environment for 1 of 4 residents (R4) reviewed for home like environment in the sample of 9.The findings include: R4's admission Record, dated 11/18/25, documents R4 was admitted to the facility on [DATE] and was discharged on 10/30/25R4's Minimum Data Set (MDS), dated [DATE], documents R4 was cognitively intact.On 11/13/25 at 1:24 PM, V5, R4's Daughter/Power of Attorney (POA), stated (R4's) room window had a hole in it and flies were getting in. I went to the store and bought some tape to cover the hole and a fly swatter to kill the flies.On 11/13/25 at 3:00 PM, V7, Maintenance Director, stated he is not aware of any windows that may have a hole in them. V7 stated the staff will put a work order on his door and he addresses them that same day. V7 stated if there was a window with a hole in it, he would have to ask his Regional Manager for approval to have a new glass cut for that window, in the meantime, he has sheets…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse by failing to perform background check screenings on current employees, having direct contact with residents. This failure has the potential to affect all 79 residents residing in the facility. This failure resulted in R4 who has a diagnosis of Bipolar Disorder, Depression and Anxiety, experience verbal abuse from a staff member and feeling fear, anger, ashamed and not wanting to come out of room until 8/21/2025. Findings include: R4's Care Plan, not dated, does not address abuse in R4's active care plan.R4's Minimum Data Set (MDS), dated [DATE] and 7/29/2025, documents that R4 is cognitively intact.R4's Serious Injury Incident and Communicable Disease Report, dated 6/20/2025, documents that R4 reported that a few weeks ago, kitchen staff member used inappropriate language towards him.R4's Serious Injury Incident and Communicable Disease Report, dated 6/20/2025,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse by failing to perform background check screenings on current employees, having direct contact with residents. This failure has the potential to affect all 79 residents residing in the facility. This failure resulted in R4 who has a diagnosis of Bipolar Disorder, Depression and Anxiety, experience verbal abuse from a staff member and feeling fear, anger, ashamed and not wanting to come out of room until 8/21/2025. The Immediate Jeopardy began on 9/30/2024. The survey team validated the abatement on 9/15/2025 at 10:46 AM. The facility remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of policies and procedures and the in-service training.Findings include: R4's Care Plan, not dated, does not address abuse in R4's active care plan. R4's Minimum Data Set (MDS), dated [DATE] and 7/29/2025, documents that R4 is cognitively…

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 failed to provide enough CNAs (Certified Nursing Assistants) and Nurses when reviewed for staffing in the sample of 8. This failure has the potential to affect all 81 residents residing in the facility.Findings Include:On 8/15/25 at 8:50 AM, an initial tour of the facility was conducted with 2 CNAs and 2 Nurses working.On 8/15/25 at 10:00 AM, a follow up tour of the facility was conducted with 5 CNAs and 3 Nurses working.On 8/15/25 at 8:40 AM, R1 stated they don't have enough staff because they've had to use more agency staff the past two weeks so they must need more staff. On 8/15/25 at 8:40 AM, R3 stated he has fallen 3 times; he fell when he was getting up to go to the bathroom. R3 stated this last time, he slid off the bed and his a hit the floor. R3 stated when he fell the first 2 times, staff helped him up right away, this last time, he couldn't reach his call light, so he crawled to the hallway, and there were crickets no one came, so he crawled back to his bed, reached for his cell phone and called 911. R3 stated he…

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 residents family of a fall in 1 of 4 residents (R8) reviewed for falls in the sample of 8.Findings Include:R8's Face Sheet, undated, documents R8 has the following diagnoses: Catatonic Schizophrenia, Anxiety Disorder, Repeated Falls, Hypertension, Major Depressive Disorder, and Type II Diabetes. R8's Minimum Data Set, dated [DATE], documents R8 has a BIMS (Brief Interview of Mental Status) score of 6, which indicates R8 has severe cognitive impairment. R8's Progress Notes document R8 had a fall on the following dates: 6/15/25; 7/4/25; 7/26/25; 7/27/25; 8/5/25; 8/7/25; 8/12/15; and two falls on 8/16/25. R8's progress notes fail to document that V18, R8's Family, was notified of these falls and any injuries sustained due to the fall.On 8/18/25 at 10:17 AM, V18, R8's Family, stated the facility used to notify him when R8 had fallen but they have not been doing that recently. V18 stated when he came in to see R8 the last time, R8 had a cut above…

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 interviews and record reviews, the facility failed to provide medical records for 1 out of 1 residents (R3) reviewed for resident rights. Findings include: R3's face sheet documented she was admitted to the facility on [DATE] and discharged on 3/17/25 with diagnosis of, in part, metabolic encephalopathy, epilepsy, vascular dementia, and major depressive disorder. R3's MDS dated [DATE], documented she was moderately cognitively impaired. R3's State of Illinois: HIPAA (Health Insurance Portability and Accountability Act) Complaint Authorization for the Release of Patient Information Pursuant to 45 CFR (Code of Federal Regulations) 164.508 form documented V6 (R3's Daughter/Power of Attorney) completed it on 3/18/25. On page two of the State of Illinois: HIPAA Complaint Authorization for the Release of Patient Information Pursuant to 45 CFR 164.508 form, it documented the covered entity must act on a request for access no later than 30 days after receipt of the request and once processing is completed,…

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 interviews, observations, and record reviews the facility failed to implement and/or revise an individualized plan of care following falls as well as complete a fall risk evaluation for 3 out of 5 residents, (R1, R2, R3); reviewed for accident hazards and supervision in a sample of 5. Findings include: 1.R1's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic obstructive pulmonary disease, anxiety disorder and chronic kidney disease. R1's Care Plan with an initiation date of 4/7/25, documented R1 had an actual fall with no injury; on 4/6/25 an unwitnessed fall, on 4/8/25 an unwitnessed fall with no injury; on 4/8/25 three unwitnessed falls with no injury, 4/10/25 unwitnessed fall with no injury, on 4/17/25 an unwitnessed fall with no injury, on 4/19/25 an unwitnessed fall with no injury, on 4/20/25 an unwitnessed fall, golf ball hematoma on head, and on 5/15/25 a fall with no injury. Intervention placed on 4/16/25 documented R1 is encouraged to wear…

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

Based on observation, interview, and record review, the facility failed to ensure a mechanical lift was maintained in a safe working manner for 4 of 4 residents (R2, R5, R6, and R7) reviewed for equipment. Findings Include: On 05/01/25 at 8:50 AM, V3, Certified Nursing Assistant (CNA) was walking down the 300 hallway pushing a mechanical lift and having a difficult time keeping it straight. While V3 was pushing the lift the right leg would swing out on its own without the use of the controls to move it. V3 would then use her foot to kick the leg back into position. On 05/01/25 at 9:07 AM, V4, CNA and V6, CNA Brought the mechanical lift down to R2's room. While wheeling the lift to R2's room the right leg would move/swing out without V4 using the controls. V4 would put the leg back in place with her foot as she was pushing the lift to the room. V4 and V6 placed R2 in the medical lift and used the controls to lift R2 to put her to bed. While R2 was up in the lift V4 was pushing the lift over the bed the leg swung open and V4 had to kick it back in place. V4 was struggling to get 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 provide residents with a sanitary and comfortable environment for 4 of 4 (R2, R5, R6, and R7) reviewed for sanitary environment. Findings Include: On 05/01/25 at 9:35 AM, The men's bathroom on the 300 hall was inspected at this time. In the shower area between some of the tiles was black fuzzy, rough in texture spots. In the entrance to the shower there was an area where the tile was missing, and the wall was crumbling. On 05/01/25 at 9:40 AM, The women's bathroom on the 100 hallway was inspected at this time. Upon entering the bathroom there was a strong smell of bleach. Behind the entrance door there was a green substance on most of the wall. V8, Licensed Practical Nurse (LPN) was questioned about the substance behind the bathroom door. V8 stated I'm not gonna lie, it looks like mold. In the shower area of the bathroom on the wall opposite from the shower head, in both corners there was black fuzzy spots on some of the tiles/baseboards. In the corner at the entrance on the side with the shower head 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.

Based on observation, interview and record review, the Facility failed to ensure dishes were properly cleaned and food was stored in a manner to prevent foodborne illness. This has the potential to affect all 55 residents living in the Facility. Findings include: On 11/12/24 at 8:10 AM, V6, Cook, washed food residue from a dish in the far-right compartment of the three-compartment sink, dipped the dish directly into the far-left compartment of the sink containing sanitizing solution, then placed the dish on a rack to dry. V6 did not rinse the dish in between the two sinks, and the middle sink compartment was empty. On 11/13/24 at 8:15 AM, V6 stated the process is usually to wash, rinse and sanitize dishes, but they do not have a stopper for the middle sink, so she just washed and sanitized. On 11/12/24 at 8:15 AM, in the walk-in refrigerator, there was a container labeled Super Cereal that was dated 11/3/24 with no Use By date. There was a container labeled Meat Salad that was dated 11/5/24 with no Use By date. On 11/12/24 at 8:17 AM, in the walk-in freezer, there was a plastic bag…

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 thoroughly investigate an allegation of abuse for 1 of 1 resident (R26) reviewed for abuse in a sample of 43. Findings include: The Facility's Incident Investigation Form, dated 8/11/2024 at 1:30 PM documents, spoke to (R26) R/T (related to) alleged abuse on 8/9/2024 @ (at) 2:45 AM. Stated that he was hit and scratched by NOC (night) CNA (Certified Nursing Assistant). Asked (R26) about minimal swelling to RT (right) upper lip and left cheek. At first, he stated that he was in his room and was attacked by NOC (night) CNA. Informed (R26) that camera was reviewed and CNA with alleged allegations did not enter his room. (R26) then stated that NOC CNA hit him outside on the patio with (R26) during his shift. According to nurses' documentation @ times of allegation and head to toe assessment, there were no abnormal skin findings. Provider was notified, orders were received for labs, X-Ray to face. X-Ray results negative for fx (fracture.) Nursing staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to address pain on one of three resident's care plan (R3) reviewed for care plans in a sample of 43. Findings include: R3's Minimum Data Set (MDS) dated [DATE] documents resident is alert with occasional pain. Over last five days and pain effect on sleep: rarely or not at all. Over the last five days, how often have you limited your day-to-day activities because of pain? Occasionally. Numeric rating scale: 6/10. Verbal descriptor scale: not answered. R3's Physician's Order Sheet, POS, dated 11/2024 documents the following pain medications: Tramadol HCL 50 mg (milligrams) PRN (whenever necessary) every 6 hours as needed for pain, Carbamazepine 200 mg BID (twice a day) for pain, Acetaminophen 500 mg 2 tablets TID (three times a day) for pain, Gabapentin 400 mg TID for pain, Diclofenac sodium 1% gel apply topically 2 grams to ankles and knees twice a day for pain. R3's Pain assessment dated [DATE], 7/23/2024 and 10/23/2024 documents resident no…

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

Based on observation, interview, and record review the Facility failed to maintain an effective pest control program so that the facility was free of roaches. This has the potential to affect all 56 residents living in the facility. Finding include: On 6/12/2024 at 6:05 PM, V6 Licensed Practical Nurse (LPN) stated We do have roaches here. The maintenance man was supposed to be spraying but he got fired because he was never working. The roaches are really bad on the 300-hall. When I turn the light on, the roaches just scatter. On 6/12/2024 at 6:38 PM, R6 stated, I have roaches in my room. When you turn the light on they run away. I don't like bugs and or roaches. On 6/12/2024 at 7:19 PM, V1, Administrator stated, I just had to terminate (V10) our maintenance man. He was basically not working when he was supposed to be working. My company (Facility) had to file bankruptcy and (V10) was supposed to be keeping up on spraying the facility, landscaping, mowing. He was not doing it. I was finally able to get a contract for a pest control company to come in. On 6/18/2024 at 4:14 PM, V11,…

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 assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. The failure has the potential to harm all 53 resident in the facility. Findings include: Facility's Staffing Schedule dated December 16-31, 2023 documents that on 12/30/23, two nurses and one CNA (Certified Nursing Aid) were working the floor on the midnight shift. On 12/31/23, one nurse and zero CNAs worked the floor on the midnight shift. On 01/10/24 at 2:21 PM, R1 who was alert to person, place and time stated that the facility is short nurses and CNAs on Mondays and Fridays. On 01/10/24 at 3:21 PM, R2 who was alert to person, place and time stated that the facility has been short staffed since COVID. He stated that the facility is mostly short CNAs and sometimes nurses, especially on weekends and holidays. On 01/23/24 at 10:13 AM, V2, DON (Director of Nursing) stated…

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

Based on observation, interview, and record review, the Facility failed to provide an ongoing resident centered activities program to support residents in all their wellness domains. This has the potential to affect all 55 residents living in the Facility. Findings include: During the Resident Council Group Meeting on 11/15/23 at 10:02 AM, R24 stated the Facility used to have an Activities Director, but she left last December and has not been replaced. R24 stated, They have nothing for us to do around here. It's very boring. R34 stated V3, Social Services Director, is the social worker and has other things to do besides Activities. On 11/15/23 at 11:50 AM, R32 stated, We used to have activities, but we don't anymore. We want to play Bingo and go outside and go to the store. It would just give us something to look forward to. We're just bored. It just isn't right. They need to treat us like this is our home. It's important. On 11/16/23 at 1:15 PM, R1 stated the Facility used to tell them when they were going to have Activities, but they have not done that in a while. On 11/14/23 at…

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

Based on observation, interview, and record review, the Facility failed to employ a qualified therapeutic recreational specialist or activities professional to provide a resident centered activities program. This has the potential to affect all 55 residents living in the Facility. Findings include: During the Resident Council Group Meeting on 11/15/23 at 10:02 AM, R24 stated the Facility used to have an Activities Director, but she left last December and has not been replaced. R24 stated, They have nothing for us to do around here. It's very boring. On 11/15/23 at 11:50 AM, R32 stated, We used to have activities, but we don't anymore. We want to play Bingo and go outside and go to the store. It would just give us something to look forward to. We're just bored. It just isn't right. They need to treat us like this is our home. It's important. On 11/15/23 at 10:55 AM, V1, Administrator, stated they have been without a full time Activities Director for about 6 months, but V11, Facility Van Driver, has been doing Activities along with Transportation. V1 stated V11 is a Certified 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 properly store, prepare and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 55 residents living in the Facility. Findings include: On 11/14/23 at 8:15 AM, in the dry storage room there were two 12-quart containers of dry cereal that were not labeled or dated. There was a package of fried onion straws that had been opened, but was not resealed, leaving the contents open to air. There was a cabinet containing chemicals that also had a case of soda inside. V4, Dietary Manager, stated that was not intended for resident consumption and would get rid of it. On 11/14/23 at 8:19 AM, in the kitchen next to the ice machine there was a bottle of unopened soap next to the meat slicer. The meat slicer was not covered. On 11/14/23 at 8:20 AM, the walk-in refrigerator had a cart with two trays of chicken strips and two trays of chicken patties. The trays were labeled with stickers, but were not covered, leaving the chicken open to air. There was a bag of white shredded…

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 utilize the services of an Infection Preventionist (IP) at a minimum part time basis to track Facility infections and staff and resident vaccinations in order to prevent the spread of infectious disease. This has the potential to affect all 55 residents living in the Facility. Findings include: On 11/17/23 at 9:50 AM, V2, Director of Nursing (DON), stated she is acting as the IP, but has not completed the training. She just started working here about two months ago and has not yet had the time. She thinks V20, Assistant Director of Nursing (ADON) has the certification, but she is in charge of the Facility's Infection Control. On 11/17/23 at 10:25 AM, V9, Registered Nurse (RN), stated, (V2) does Infection Control for the Facility. I notify (V2) of any resident infections, diagnoses, medications, dose, and organism, if available, but (V2) does the tracking and trending. On 11/17/23 at 12:46 PM, V1, Administrator, stated they do not have a policy specific to the Infection Preventionist, but would expect the IP to have 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 ensure medications are controlled for 4 of 4 residents (R23, R27, R43, and R52) reviewed for medication storage in the sample of 50. Findings include: On 8/15/23 at 8:10 AM, V9 Registered Nurse (RN) opened the top drawer of the 300-hall medication cart to administer medications for R40. While drawer was opened, 4 clear medication cups were observed in the top drawer, with each cup containing multiple pills and capsules. There were last names on these cups, but no date or time of when they were set up or when they were to be administered. There was also an insulin syringe lying next to the cups in the drawer containing 7 units of cloudy liquid. The insulin syringe was not labeled with a name or date. V9 identified the medications she had pre-set up in the four cups as R43's, R23's, R27's, and R52's morning medications. She also identified the syringe as R43's morning dose of 7 units of Humalog insulin. V9 stated she had them ready for when the residents come up to the dining room. She stated she does 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the Facility failed to provide a clean, comfortable, homelike environment for 3 of 5 residents (R20, R34, R40) reviewed for environment in the sample of 50. Findings include: On 11/15/23 at 10:02 AM during the Resident Council Group Meeting, R24 stated, There is mold in the bathroom, and it's gross. R34 stated the bathroom toilet needs to be replaced, and she mentions it to the Facility staff all the time. She stated the bathroom is like an old sanatorium, and the baseboards are not good. R34 also added the light in the 200 Hallway Ice Room needs to be replaced. R40 stated, The first bathroom by the offices is not good. The bottom of the floor has rot. I would rather go around (to the other side of the Facility) than have to take a shower there. On 11/16/23 at 8:10 AM, the Women's Visitor Restroom next to room [ROOM NUMBER] had an area of missing tile on the wall measuring approximately 15 inches across and 24 inches long. There was a rust-colored material 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 injury of unknown origin on 2/16/23 for 1 resident (R44) in a sample of 50; Additionally the facility failed to report an allegation of physical abuse on 11/28/22 and 11/7/23 for one resident (R41) in a sample of 50. Findings include: 1. R44 Nurse's Progress Notes dated 2/16/23 documents that V14 granddaughter of R44 was combing R44's hair and observed a scar about 16 centimeters at the back of R44's head. No further documentation. R44's Face Sheet undated documents R44 was admitted to the facility 2/19/22 with a pertinent diagnosis of Dementia. R44's Minimum Data Set (MDS) dated [DATE] documents R44 has severe cognitive impairment and is Totally dependent for personal grooming and dressing. On 11/15/23 at 4:00 PM, V2 Director of Nursing (DON) stated I was not here then I can't tell you what happened but I will try to find out for you. On 11/16/23 at 8:10 AM, V2 DON stated the nurse on duty at the time was interviewed and stated it was 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 provide a complete investigation of an injury of unknown origin on 2/16/23 for 1 resident (R44) in a sample of 50; Additionally, the facility failed to provide a complete investigation on 11/28/22 and 11/7/23 for one resident (R41) in a sample of 50. Findings include: 1. R44 Nurse's Progress Notes dated 2/16/23 documents, that V14 granddaughter of R44 was combing R44's hair and observed a scar about 16 centimeters at the back of R44's head. No further documentation. R44's Face Sheet undated documents, R44 was admitted to the facility 2/19/22 with a pertinent diagnosis of Dementia. R44's Minimum Data Set, (MDS), dated [DATE] documents, R44 has severe cognitive impairment and is Totally dependent for personal grooming and dressing. On 11/15/23 at 4:00 PM, V2 Director of Nursing, (DON), stated, I was not here then I can't tell you what happened but I will try to find out for you. On 11/16/23 at 8:10 AM, V2 DON stated, the Nurse on duty at the time 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 observation, interview and record review, the facility failed to properly sanitize and store a residents BiPAP device for 1 of 12 residents (R14) reviewed for infection control in the sample of 50. Findings include: On 11/14/23 at 3:13 PM R14 stated nobody has cleaned the tubing for his BiPAP machine since he got it a few months ago. His mask for his BiPAP mask was laying on a fly swatter on his bedside table, not in a bag. R14 stated he had not used the fly swatter for a while, but he has used it to kill flies when it was hot. On 11/15/23 at 10:00 AM R14's BiPAP mask continued to lay on top of the fly swatter on his bedside table, not in a plastic bag. On 11/16/23 at 10:10 AM R14's BiPAP mask was still laying on top of a fly swatter on his bedside table, not contained in a bag. R14's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15 indicating he is alert and oriented. R14's Care Plan, Physician Order Sheet dated 11/1/23 to 11/30/23, Treatment…

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 protocol to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate antibiotics for 1 of 3 (R36) residents reviewed for antibiotic stewardship in a sample of 50. Findings include: R36's Physician Order undated documents diagnoses of schizoaffective disorder, depression episodic with catatonic features, hypertension, asthma, hyperlipidemia, history of cerebrovascular accident, and Gastroesophageal reflux disease. R36's Physician Order dated 11/07/23 documents Macrobid (antibiotic) 100 mg twice daily for 7 days. DX, (diagnosis): UTI, (Urinary tract Infection). UA, (urinalysis), today nitrite positive. Sending urine for CX, (culture). Start Macrobid BID for 7 days. Follow-up in 2 weeks to ensure resolution of UTI & reassess urinary symptoms. R36's Nurses Note dated 11/07/23 at 12:00 PM documents Resident came back to facility from urologist appt. Resident starting Macrobid 100 mg PO, (by mouth), twice a day r/t, (related to), UTI. UA today…

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 treatments and interventions as prescribed by a physician, properly document treatments per their Facility Policy, as well as continue implementing interventions listed in the resident Care Plan to prevent a resident from self-harm biting for 1 of 3 residents (R1) reviewed for quality of care the sample of 7. Findings include: R1's Comprehensive Nursing assessment dated [DATE] documents R1 has a diagnosis of anxiety and a mood disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 was cognitively impaired, had a behavior that occurred daily and put R1 at significant risk for physical illness or injury. R1's Care Plan dated 1/12/2023 documents, Resident has (an) anxiety problem which causes him to bite on hands and fingers. It further documents, Make sure he has his teddy bear to hold. R1's Care Plan has not been updated to reflect the use of geri-sleeves. R1's Psychiatric Consult dated 5/2/2023 documents R1 has a history of anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to employ a Registered Nurse, (RN), in the role of full time Director of Nursing, (DON), coverage in the facility from June 2023 to August 9, 2023. This has the potential to affect all 55 residents residing in the facility. Findings include: The Facility's Schedule, dated June 2023, July 2023, and August 2023 documents, V2, Regional DON, was only at the Facility on 6/7/23, 6/13/23, 7/4/23, 7/6/23, 7/7/23, 7/10/23, 7/11/23, 7/18, 7/21/23, 7/23/23, 7/24/23, 7/25/23, 7/26/23, 7/27/23, 8/1/23, 8/2/23, 8/8/23. On 8/8/2023 at 12:30 PM V1, Administrator, stated, that the Census was 55. V1 stated, that they have a Regional DON, V2. V1 stated, that they have RN, (Registered Nurse), coverage and V2 assists with this coverage. On 8/9/2023 at 12:37 PM V1 stated, that V7, RN, was the previous DON. V1 stated, that last day was June 20th, 2023. V7 stated, that she is actively looking for a DON. V7 stated, that she is advertising, utilizing social media,…

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, observations, and interviews, the facility failed to maintain an effective pest control program for 4 of 4 (R1, R2, R6, R7) rooms reviewed for insect presence. Findings included: 1. R7's MDS, dated [DATE], documents, that R7 is cognitively intact and requires assistance from staff for assistance with activities of daily living, (ADL). R7's Care Plan, dated 1/16/23, documents, that R7 has a self-care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADLs. It continues Assist with ADL's as necessary with staff assist of 2. On 8/8/2023 at 1:31 PM, R7 stated, that the facility has a lot of flies. R7 stated, that they are horrible at times. R7 stated, that she swats at them and try to kill them. R7 stated, that she spends a lot of time in her room and that's where the flies and fruit flies are. On 8/8/2023 at 3:39 PM observed R7 sitting in room on the bed. Observed multiple flies in room. Observed a fly on the headboard, 1 on R7's leg, 1 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 provide timely toileting assistance to prevent incontinence episodes in order to maintain dignity for 1 of 3 residents (R1) reviewed for dignity in the sample of 8. Findings include: 1. R1's Nurse's Notes dated 7/19/2023 documents R1 arrived at the facility from the local hospital with a primary diagnosis of a fracture right hip. R1's Nursing admission assessment dated [DATE] documents R1 is continent of bowel and bladder. R1's Skilled Progress Note dated 7/23/2023 documents R1 is continent. R1's Minimum Data Set, dated [DATE] documents R1 is occasionally incontinent of bladder. On 8/1/2023 at 9:06 AM V4, R1's Daughter in Law, stated R1 was continent prior to coming to the Facility. V4 stated the staff made R1 lay in urine for hours on end. V4 stated R1 called her and said, I'm laying here in a puddle of pee and had to wiggle her way down to the end of her bed to get to her wheelchair so R1 could get out of the urine. On 8/1/2023 at 9:15 AM, R1 stated,…

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