Goldwater Care Danville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to thoroughly investigate injuries of unknown origin for two of four residents (R2, R3) reviewed for injuries in the sample list of five. Findings include: The facility's Abuse Prevention and Reporting - Illinois policy dated 10/24/22 documents employees are required to report allegations or suspicions of potential abuse/neglect immediately to the administrator and abuse incidents/allegations will be investigated. This policy documents injuries of unknown source are when the source of the injury was not observed or could not be explained by the resident, and the injury is suspicious due to the extent or location of the injury (an area not generally susceptible to injury/trauma) or the number of injuries at one particular point or incidents of injuries over time. This policy documents the same time frames for reporting and investigating abuse will be followed for injuries of unknown source. This policy documents at a minimum, attempt 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 thoroughly investigate a fall to identify the root cause and determine appropriate post fall interventions for one of three residents (R4) reviewed for falls in the sample list of five. Findings include: On 6/24/25 at 11:00 AM R4 was in bed and stated R4 needed to use the bathroom. R4 was asked to turn her call light on and R4 demonstrated ability to activate her call light. V21 Human Resources entered R4's room and instructed R4 to wait for nursing staff assistance. R4 did not wait for staff assistance and self ambulated to the bathroom with her wheeled walker. At 11:07 AM R4 was sitting on the side of bed and R4's wheeled walker was at the foot of R4's bed. R4 had adhesive strips covering a small scabbed wound on R4's forehead. R4 stated R4 fell while R4 was walking in her room, moving things from a dresser drawer to R4's closet. R4 stated R4 did not ask for staff assistance, but staff were in the hallway outside of R4's door at that…

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 maintain an accurate medical record for one of three residents (R4) reviewed for falls in the sample list of five. Findings include: The facility's undated Neurological Assessment policy documents to complete neurological assessments when a resident experiences a head injury or when ordered by a physician for a change in resident's condition. This policy documents to observe, assess and document the resident's level of consciousness, speech, pupils, hand grasps and vital signs as part of this assessment. The facility's undated Medical Record Policy documents the facility will maintain complete and accurate resident medical records, and in accordance with applicable federal and state regulations. R4's Minimum Data Set, dated [DATE] documents R4 has severe cognitive impairment. R4's Nursing Notes document on 6/16/25 at 5:30 PM R4 lost balance and fell, neurological assessments were initiated and R4 was transferred to the hospital. R4 returned 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 observation, interview, and record review the facility failed to verify placement of a gastric feeding tube prior to instilling flush and medications and failed to flush the tube between medications for one resident (R1) of three residents reviewed for medication administration in a sample list of four. Findings Include: The facility's policy Medication Administration -Gastrostomy or Nasogastric Tube reviewed 8/3/20 states Check tube for proper placement: Aspirate to visually verify stomach contents. Gastric fluid normally appears clear or yellow with mucus or may appear milky if residual remains from previous feeding. Aspirated contents must be returned to the stomach to maintain ph (Acid Base Balance), fluid and electrolyte balance. This policy also states if more than one medication is being given at a dosing time, administer each medication separately, flushing the tube with approximately 10 milliliters of tepid water between medications, or enough to clear the tubing. Tablets will finely pulverize and disperse well in tepid water. On 5/8/25 at 11:45AM V7, RN…

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 enhanced barrier precautions (EBP) for one resident (R2) of three residents reviewed for EBP in a sample list of three residents. Findings include: R2's current diagnoses list includes the following diagnoses: Dementia, Benign Prostatic Hypertrophy with Hyperplasia of the Lower Urinary Tract, Obstructive and Reflux Uropathy. R2's Physician's Orders for April 2025 include a physician's order for a Suprapubic Catheter. On 4/17/25 at 9:05AM V5, RN completed suprapubic catheter care for R2. V5 washed hands, donned gloves, removed the old dressing, cleaned the stoma and tubing with wound cleanser, rewashed hands, donned clean gloves, applied the stoma dressing as ordered, removed gloves, and washed hands per protocol. V5 did not wear a gown to complete this procedure. Isolation linen and trash containers were in R2's room and a cart with isolation supplies were outside R2's door. There was sign on R2's door indicating transmission-based precautions are in place. Per lab results dated 2/19/24 R2 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the licensed staff maintains a current state license. This failure has a potential to affect all 79 residents in the facility. Findings include: On [DATE], V42's employee file was requested and reviewed. V42's file contained the nursing license verification of LPN (Licensed Practical Nurse) license was conducted through the Illinois Department of Federal Professional Regulations site on [DATE]. The license verification showed V42's LPN license will expire on [DATE]. A copy of V42's nursing license was in the employee file with an expiration date of [DATE]. On [DATE] at 2:55 PM, V41 Human Resources stated that the professional licenses are kept in the employee file and in a binder. V41 checked the license binder and was unable to locate the new nursing license for V42. V42's employee file contained the nursing license that expired on [DATE]. On [DATE], V42's timecard and the facility daily staffing logs shows that V42 worked in the…

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

Based on observation, interview, and record review the facility failed to administer medications timely, as ordered, and in accordance with pharmacy instructions resulting in five medication errors out of 25 opportunities, a 20% medication error rate. This failure affects two of five residents (R14, R47) reviewed for medication administration in the sample list of 51. Findings include: 1.) On 4/01/25 at 8:45 AM V13 Registered Nurse (RN) prepared R14's medications. V13 obtained a vial of R14's Cyclosporine 0.05% eye drops and the box contained a label to turn the vial upside down several times prior to use. V13 placed two pumps of topical menthol 5% gel into a medication cup. V13 did not turn the Cyclosporine vial upside down several times prior to administering one drop into R14's eyes. V13 applied the topical menthol gel to R14's knees. R14's April 2025 Medication Administration Record (MAR) documents R14 receives Cyclosporine 0.05 % one drop each eye twice daily and Biofreeze Pain Gel 4% menthol topically to knees four times daily. On 4/01/25 at 9:51 AM V13 verified menthol 5% gel…

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 label insulin vials with opened dates, appropriately store medications and destroy discharged resident medications for four of six residents (R187, R186, R47, R82) reviewed for medication storage in the sample list of 51. Findings include: 1.) On 04/01/25 at 1:57 PM the Middle Hall medication room was observed with V47 Licensed Practical Nurse. There was a bottle of R186's Clindamycin 300 milligrams (mg) containing three capsules. There was a bag of three vials of Ceftriaxone 1 gram labeled with R187's name. V47 stated these residents are no longer in the facility and have not been here since V47 started working in the facility a few months ago. V47 stated night shift is suppose to send medications back to the pharmacy. R187's Census documents R187 discharged from the facility on 12/13/24. R186's Census documents R186 discharged from the facility on 12/18/24. On 4/2/25 at 11:42 AM V8 Assistant Director of Nursing (ADON) stated after a resident discharges their medications should be returned to the pharmacy. If…

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

Based on observation, interview and record review, the facility failed to provide care in a manner and environment that promotes resident's independence and dignity while dining for two (R7, R46) of 18 residents reviewed for residents' rights in a sample size of 51. Findings include: R7's care plan, dated 12/7/24, documents R7 has a diagnosis of Multiple Sclerosis and bilateral cataract age related disease. R7 is a social person and enjoys people. R46's care plan, dated 9/17/24, documents R46 is a social person and enjoys people. R46's has a diagnosis of severe protein deficiency malnutrition as well as a diagnosis of dysphagia that requires assistance and supervision with fluid intake and meals. On 03/31/25 at 12:15 pm The noon meal in the main dining was served. R7 and R46 were served plated meals on cafeteria style trays, while other residents seated at the same table were served by removing plates from trays and placing in front of resident along with utensils needed for the meal. R7 was not properly positioned in a low seated wheelchair resulting in R7's shoulders being level…

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 an individualized care plan that included interventions for end of life care. This failure has the potential to affect one (R76) of one resident reviewed for Hospice on a sample list of 51. Findings include: The hospice admission evaluation note dated 1/8/25 documents that R76 was admitted to (Hospice Company). On 04/01/25 at 01:14 PM, V2, Director of Nursing (DON) stated that the facility communicates with the Hospice team via a communication book and that R76's care plan should be in the communication book. V2 provided the communication book and there was no communication found on R76. On 04/02/25 at 09:21 AM , V9 Registered Nurse/Care Plan Coordinator stated that R76 is on hospice and should have a care plan with interventions in place. V9 stated V9 is new to this position, V9 started in January 2025 and is trying to catch up. On 04/02/25 at 09:31 AM, V2, stated that R76 should have had a care plan put in place when R76 was admitted to hospice. On 04/02/25 at 1:53 PM, V2 provided R76's hospice plan of care dated…

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 review and revise a Care Plan in a timely manner for one (R76) of eighteen residents reviewed for advanced directives on the sample list of 51. 04/01/25 01:21 PM, R76's Care Plan dated 1/9/25 documents that R76 is a full code. On 04/01/25 at 12:48 PM, R76's medical record documents that she signed a code status form on 1/3/25 documenting that R76 doesn't want to be resuscitated. On 4/2/25 at 12:45 PM, V9 Care Plan Coordinator stated that social services usually take care of getting a resident's code status form signed and put into the medical record. V9 stated that she noticed today that R76 was a full code on the care plan. V9 stated the code status should have been updated on the care plan as soon as possible after it was signed. On 4/2/25 at 12:50 PM, V28 Social Services stated that she should have entered R76's code status in the medical record.

Based on observation, interview, and record review the facility failed to provide oral care for one (R55) of 24 residents reviewed for ADL (Activities of Daily Living) care in a sample list of 51. Findings Include: The facility's policy Oral Hygiene updated 1/1/14 states: Oral care is an essential part of morning and evening care. Note: Some residents may require oral hygiene after each meal due to inability to rinse out food debris. R55's current diagnosis list includes the following diagnoses: Dysphagia following Cerebral Vascular Accident, Seizures, Anxiety, and Dementia with Behaviors. On 1/31/25 at 10:00AM R55 was lying in bed sleeping. R55 was breathing through R55's mouth with her mouth open. A large amount of crusty gray secretions were noted on R55's lips and oral cavity. On 4/2/25 at 10:00AM V8, ADON (Assistant Director of Nursing) verified it is the facility's expectation all residents who require assistance with oral care should receive it as needed. V8 also verified this is particularly important in residents with Dysphagia (difficulty swallowing).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to document assessments and obtain treatment orders for newly identified pressure ulcers, develop a care plan for pressure ulcers, develop and implement pressure relieving interventions, and timely implement treatment orders for one of four residents (R38) reviewed for pressure ulcers in the sample list of 51. Findings include: The facility's Pressure Injury and Skin Condition assessment dated [DATE] documents the following: A Braden pressure ulcer risk assessment will be completed on admission, quarterly and as needed, and nurses will complete weekly skin assessments for identified residents. Document an initial wound assessment in the resident's medical record when pressure ulcers are identified. The physician will be notified at the earliest sign of a pressure ulcer. The care plan will be updated to include skin integrity, goals, and interventions. Physician ordered treatments will be documented on the Treatment Administration Record 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 obtain physician orders for oxygen use and provide hygienic care and storage of nebulizer equipment for two of two residents (R36, R185) reviewed for respiratory care in the sample list of 51. Findings include: 1.) On 3/31/25 at 10:01 AM R36 was in bed wearing oxygen at 3 liters per minute. R36's nebulizer mask and tubing was uncovered in an open drawer of R36's night stand. R36 stated R36 gets daily nebulizer treatments. R36's March 2025 Medication and Treatment Administration Record (MAR/TAR) documents R36 receives Ipratropium-Albuterol nebulizer treatments four times daily and does not include an order and schedule to change nebulizer tubing. On 3/31/25 at 2:10 PM V45 Registered Nurse stated nebulizer tubing and mask should be changed weekly which is done by night shift and documented on the MAR/TAR. At 2:18 PM V45 entered R36's room and verified R36's nebulizer mask was uncovered and on top of R36's night stand. V45 stated night shift…

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 periodically assess psychotropic medication use, identify targeted resident behaviors, attempt nonpharmacological interventions, and avoid duplicate therapy for three residents (R4, R26, R64) of five residents reviewed for unnecessary medications in a sample list of 51. Findings include: The facility's policy Psychotropic Medication revised 2/1/18 states Purpose: To ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per standards of practice, and are prescribed at the lowest therapeutic dose to treat such conditions. The plan to alternatives to psychotropic medication and/or use of psychotropics shall be incorporated into the care plan with suitable goals and approaches. This will be initiated by the resident's needs/problems, goals, and approaches as it relates to the use of psychotropic drugs. 1. R4's current Medication Administration Record (MAR) for April 2025 includes the following psychotropic medications: Olanzapine…

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 use sanitary practice to handle and administer medications to residents. This failure has the potential to affect all 81 residents in the facility. Findings include: On 1/29/24 at 9:45 AM, V10, Registered Nurse, was actively engaged in medication administration duties preparing residents' medications. V10 was manually opening drawers of the medication storage cart, removing and replacing medications cards in the drawers, and manipulating the computer mouse, all with bare hands. V10 was removing residents pills from the cards and placing them into her same bare hands then placing the pills into a small plastic cup to administer to residents. V10 stated she knew she wasn't supposed to be putting pills into her bare hands before placing the pills into the cup. V10 stated the resident she was preparing medications for at that time was R7 On 1/29/25 at 11:12 AM, V2, Director of Nursing, was actively engaged in medication administration duties preparing residents' medications. V2 was manually opening drawers of the…

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

Based on interview and record review, the facility failed to acquire and administer medications to meet the needs of residents. This failure affects one resident (R1) out of seven reviewed for medications. Findings include: On 1/28/25 at 12:12 PM, V11, Family of R1, stated the facility did not have available R1's Ativan (anti-anxiety) for two days. V11 further stated she had found 2 pills in R1's bed and did not believe the nurses at the facility were making sure R1 took her medicine. V11 stated one of the pills she found in R1's bed was Zoloft (anti-depressant). R1's current Physician Order Sheet (POS) dated 1/28/25 documents R1 had physician orders for Lorazepam (Ativan) 0.5 milligrams (mg) twice daily scheduled at 8:00 AM and 8:00 PM. This same POS documents R1 had physician orders for Zoloft 75 mg every bed time at 8:00 PM, and Docusate (Colace) 100 mg every morning at 8:00 AM. This same POS documents R1 had a physician order to receive a Cyanocobalamin (B-12) injection of 1,000 micrograms monthly which was scheduled for the 17th of January 2025. On 1/28/25 at 10:31 AM, V4,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a full time director of nurses to oversee and coordinate nursing services provided within the facility. This failure has the potential to affect all 77 residents residing in the facility. Findings Include: On 11/20/24 and 11/22/24 there was no staff member in the facility designated as the Director of Nursing (DON) or DON present at the facility. On 11/20/24 at 9:00 AM, V1, [NAME] President of Operations, stated, There is no DON (Director of Nursing) right now. The former DON (V24) resigned as of 11/9/24. We did hire a new DON to replace the former one but then the new one decided not to come work at this facility. On 11/22/24 at 12:40 PM, V1 further stated, We do have a Regional Nurse covering this building but she is sick, and we have a second Regional Nurse, so between the two of them, I would say they are here more than part time but not full time. On 11/20/24 at 9:30 AM, V8, Registered Nurse, stated, We have no DON right now…

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

Based on observation, interview, and record review, the facility failed to provide the services of a full time administrator to oversee and ensure applicable regulations are met in facility and ensure for operations and provision of resident services. This failure has the potential to affect all 77 residents residing in the facility. Findings Include: On 11/20/24 at 9:20 AM, V1, [NAME] President of Operations, stated, The administrator (V25) was in a motorcycle accident back in September and we are not sure if she will be coming back to work. We have considered hiring (V2, Human Resources Manager) as the administrator in training. On 11/20/24 and 11/22/24, there was no full time staff member present in the facility Licensed as a Nursing Home Administrator. The Illinois Administrative Code Title 77 Department of Public Health Long Term Care Facilities Skilled Nursing Code documents Section 300.510 Administrator, a) There shall be an administrator licensed under the Nursing Home Administrators Licensing and Disciplinary Act full-time for each licensed facility. The facility Illinois…

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

Based on interview and record review, the facility failed to implement a quality improvement review for an adverse event resulting in a resident's (R1) death. This failure has the potential to affect all 77 residents residing in the facility. Findings Include: On 11/22/24 at 10:45 AM, V1, [NAME] President of Operations, stated, This incident was never reported to any of us (corporate staff), or the regional nurses. The first I heard of it was when you (surveyors) came in 2 days ago. V1 further stated, We would have done staff education and all the things we needed to do at that time (9/19/24). On 11/22/24 at 12:45 PM, V1 stated there had been no QAPI/ QA (Quality Assurance Performance Improvement/ Quality Assurance) reviews or risk management reviews conducted as a result of the aspiration incident involving R1. On 11/22/24 at 9:18 AM, V24, Registered Nurse/ former Director of Nursing, stated that there had been no reviews or staff education conducted after the incident involving R1 and stated, We all just kind of moved on. On 11/26/24 at 3:20 PM, V2, Human Resources Manager, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure nursing staff honored a resident's right for their choice of life-sustaining treatment preferences. This failure affected one of three residents (R1) reviewed for Advance Directives on the sample list of three. Findings Include: The Advance Directive Policy dated [DATE] documents the purpose of the policy is to ensure all residents or resident representatives are informed concenring the right to accept or refuse medical treatment and formulate an Advanced Directive. If a resident or health care representative indicates an Advanced Directive regarding Cardio Pulmonary Resucitation or Scope of Treatment (Practitioner Orders for Life-Sustaining Treatment POLST), the appropriate forms will be completed. Advanced Directive(s) shall be included in the resident's plan of care, and will be reviewed during the care plan meeting with the resident and/or the resident's legal representative when present. R1's Progress Note dated [DATE] documents R1 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, record review and interview the facility failed to ensure facility nursing staff had the appropriate competencies and skills required to provide residents with potentially life saving nursing services. This failure affected one of three residents (R1) reviewed for Dysphagia and aspiration risk on the sample list of three. Findings Include: The Facility Assessment, last reviewed on February 2024 documents the facility will ensure staff are educated and have competencies in the areas that are necessary to provide the level and type of support and care needed for their resident population. This includes specialized care such as oxygen administration and suctioning. The same assessment documents the facility on average within an typical month has eight residents requiring oxygen respiratory services and one resident requiring suctioning. (This is a typical month, not taking into an account emergency medical situations.) R1's Progress Note dated 9/19/24 documents R1 was diagnosed with Esophageal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a quarterly financial statement to two of three residents (R7 and R8) reviewed for resident funds on the sample list of 10. Findings include: 1.) R7's Minimum Data Set (MDS) dated [DATE] documents R7's Brief Interview of Mental Status (BIMS) score as 15 out of a possible 15, indicating R7 has no cognitive impairment. On 6/26/24 at 4:10 pm R7 stated she had not received a quarterly statement since the new company took over the facility ownership last year. R7's Medicaid/Medicaid Pending/Responsible Party form dated 11/20/2019 and signed by R7, documents R7 agreed to make the facility representative payee to manage R7's income. R7's Quarterly Statement For The Period Of 12/30/23- 3/29/24 was signed by R7 during this survey, dated 6/26/24. 2.) R8's MDS dated [DATE] documents R8's BIMS score as 15 out of a possible 15, indicating R8 has no cognitive impairment. On 6/26/24 at 1:44 pm R8 stated R8 has never received a financial statement of her funds…

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 physician/provider of a significant bruise for one of five residents (R2) reviewed for falls/injury of unknown source in the sample list of 10. Findings include: R2's Physician Order Summary Report Sheet (POS) dated 5/29/24 documents R2 was admitted to the facility on this same date. R2's POS also documents the following diagnoses: Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter For Closed Fracture With Routine Healing. Unspecified Dementia and a History of Falling. R2's (MDS) Minimum Data Set, dated [DATE] documents R2's (BIMS) Brief Interview of Mental Status score as seven out of a possible 15, indicating severe cognitive impairment. On 6/24/24 at 4:47 pm V22, R2's Family Member stated R2 had a bruise on R2's knee that was of unknown origin. On 6/27/24 at 12:15 pm V17, Registered Nurse/Wound Nurse provided R2's Wound Assessment Detail Report dated 6/17/24. R2's assessment documents R2 had a left knee bruise, dark…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain a wheelchair free of sharp edges to prevent injury during a mechanical lift transfer and failed to implement fall interventions to prevent falls for three of five residents (R2, R9 and R10)reviewed for injury of unknown origin/falls on the sample list of 10. Findings include: 1.) R10's Diagnoses Sheet updated 5/27/24 documents the following: Dementia, Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Peripheral Vascular Disease, Unspecified, Restless Leg Syndrome, Spinal Stenosis Lumbar Region Without Neurogenic Claudication, and Muscle Weakness. R10's Minimum Data Set (MDS) dated [DATE] documents R10 has severe cognitive impairment. R10's Health Status Note dated 6/18/2024 at 3:08 pm, documents the following: Note Text: IP (V17, Registered Nurse/Wound Nurse/ Infection Control Preventionist) was notified by CNA ( unidentified Certified Nursing Assistant) of noticing 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 ensure staff were trained in the areas identified in its facility assessment. This failure has the potential to affect all 67 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] includes, but is not limited to, the following staff training topics: effective communication, resident rights, the facility's infection control program, antibiotic stewardship, 12 hours annual in-service training for Certified Nursing Assistants (CNAs) that includes Dementia training, identifying changes in condition, and Quality Assurance Performance Improvement (QAPI) program. The facility's in-services (requested for the past year) provided by V1,was reviewed. There is no documentation that training was conducted for all staff within the last year on the training topics listed in the Facility Assessment. On 6/11/24 at 3:45 PM a list of training documentation for QAPI, Infection Control, Resident Rights, and Communication 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 conduct ongoing training in effective resident care communications for all staff. This failure has the potential to affect all 67 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] includes effective communication as a staff training topic. The facility's in-services (requested for the past year) provided by V1 Administrator,was reviewed. There is no documentation that effective communication training was conducted within the last year. On 6/11/24 at 3:45 PM and 6/12/24 at 10:15 AM V1 Administrator was requested to provide documentation of staff training, including effective communication, that was conducted within the last year. On 6/12/24 at 3:25 PM V1 stated V1 had no additional staff training documentation to provide. The facility's resident roster dated 6/10/24 documents 67 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct ongoing training in Resident Rights for all staff. This failure has the potential to affect all 67 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] includes Resident Rights as a staff training topic. The facility's in-services (requested for the past year) provided by V1 Administrator,was reviewed, and there is no documentation that an all staff training was conducted on Resident Rights. On 6/11/24 at 3:45 PM and 6/12/24 at 10:15 AM V1 Administrator was requested to provide documentation of staff training, including Resident Rights, that was conducted within the last year. On 6/12/24 at 3:25 PM V1 stated V1 had no additional staff training documentation to provide. The facility's resident roster dated 6/10/24 documents 67 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct ongoing staff training on the facility's Quality Assurance Performance Improvement (QAPI). This failure has the potential to affect all 67 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] includes QAPI as a staff training topic. The facility's in-services (requested for the past year) provided by V1 Administrator, and there is no documentation that an all staff training was conducted on QAPI. On 6/11/24 at 3:45 PM and 6/12/24 at 10:15 AM V1was requested to provide documentation of staff training, including QAPI, that was conducted within the last year. On 6/12/24 at 3:25 PM V1 stated V1 had no additional staff training documentation to provide. The facility's resident roster dated 6/10/24 documents 67 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct ongoing staff training on the facility's Infection Control Program. This failure has the potential to affect all 67 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] includes staff training on infection control program, standards, policies, and procedures. The facility's in-services (requested for the past year) provided by V1 Administrator, was reviewed, and there is no documentation that an all staff training was conducted on the facility's Infection Control Program. On 6/11/24 at 3:45 PM and 6/12/24 at 10:15 AM V1 Administrator was requested to provide documentation of staff training, including the facility's infection control program, that was conducted within the last year. On 6/12/24 at 3:25 PM V1 stated V1 had no additional staff training documentation to provide. The facility's resident roster dated 6/10/24 documents 67 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs), providing care to residents, received 12 hours of annual in-service training . This failure has the potential to affect all 67 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] documents CNAs will have 12 hours of annual in-service training which includes training on Dementia. This assessment documents Dementia as one of the common diagnoses of residents that reside in the facility. The facility's in-services (requested for the past year) provided by V1 Administrator, was reviewed, and there is no documentation that training was conducted on Dementia. On 6/12/24 at 8:45 AM V1 Administrator provided a stack of staff in-services and training. V1 stated V2 Director of Nursing does the monthly in-services with the CNAs, but do not have a log to track each CNAs attendance or receipt of training for the annual 12 hours of in-service training. V1 stated the facility…

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 ongoing behavioral health training for staff providing resident care. This failure has the potential to affect all 67 residents residing in the facility. Findings include: The facility's Facility assessment dated [DATE] documents to consider staff competencies including caring for residents with mental or psychosocial disorders, history of trauma/Post Traumatic Stress Disorder, and implementing nonpharmacological interventions. This assessment lists psychiatric and mood disorders as some of the common diagnoses of residents that are cared for in the facility. The facility's in-services (requested for the past year) provided by V1 Administrator,were reviewed, and there is no documentation that a training was conducted on behavioral health. On 6/11/24 at 3:45 PM and 6/12/24 at 10:15 AM V1 Administrator was requested to provide documentation of staff training, including behavioral training, that was conducted within the last year. At 3:25 PM V1…

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 maintain residents' complete and accurate medical records. This failure affects five (R1, R2, R3, R6, R7) of five residents reviewed for physician visits in the sample list of 16. Findings include: The facility's undated Medical Record Policy documents complete medical records will be maintained for each resident to ensure each resident's medical record is accessible and organized to facilitate compilation of information and communication between health care professionals. This policy documents physician progress notes shall be recorded in the resident's record at the time of each visit, and including at least every 30 days for the first 90 days and then at least every 60 days. 1. On 6/11/24 R1's electronic medical record (EMR) did not contain physician progress notes after 12/22/23. 2. R2's Care Plan revised 5/24/24 documents R2 admitted to the facility on [DATE] and V23 is R2's primary physician. On 6/11/24 R2's EMR did not contain physician progress…

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 physical abuse to the state survey agency for two (R8, R9) of 14 residents reviewed for abuse in the sample list of 16. Findings include: The facility's Abuse Prevention and Reporting-Illinois policy dated 10/24/22 documents physical abuse includes hitting and resident to resident altercations should be reviewed as potential abuse. This policy documents that resident to resident altercations involving willful action that results in physical injury, mental anguish or pain will be reported as required by regulation. This policy documents the facility will notify the Department of Public Health of abuse allegations initially and the results of the investigation within five working days. The facility's 2024 Abuse Tracking Log documents a physical abuse allegation/altercation involving R8 and R9 on 5/8/24. The facility's investigation to R8's/R9's 5/8/24 incident dated 5/12/24, documents the following: V18…

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 have an agreement for outside services for behavioral health needs. This failure affects one (R2) of 14 residents reviewed for abuse in the sample list of Findings include: The facility's Facility assessment dated [DATE] documents behavioral and mental health providers, behavioral aides, Psychologist, and Psychiatrist are part of the staff/health care professionals/medical practitioners that are needed to provide support and care for the residents. R2's Care Plan dated 5/24/24 documents R2 has diagnoses of Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. This Care Plan documents R2 has behaviors of physical inappropriate touching towards female residents due to R2's dementia and poor impulse control and includes interventions to analyze the time of day, places, circumstances, triggers, and what de-escalates the behavior; encourage acceptable behaviors; involve physicians and counseling services to deter inappropriate behaviors; maintain…

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 rights to be free from sexual abuse by another resident. This failure affects four residents (R1, R2, R8, R9) reviewed for abuse in the sample of nine. Findings Include: A Facility Reported Incident dated 2/20/24 and corrected with actual date of 4/7/24 documents R1 asking a visitor (V5) to remove R1 from an area (lounge) and take R1 to an activity. R1 reported to the visitor that R1 was afraid of another resident (R2). V5 reported this immediately to V3 (Activity Aide). V3 spoke with R1 privately and R1 told V3 that R2 had been following R1 around and R2 had rubbed R1's chest. It was reported to V1 (Administrator) right away. R1's Diagnoses Sheet (current) includes the following diagnoses: Insomnia, Urine Retention and Congestive Heart Failure. R1's Minimum Data Set, dated [DATE] documents R1 being moderately cognitively impaired and using a wheelchair for mobility purposes. R2's Diagnosis Sheet (current) includes the following…

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 store medications and biologicals in a locked area, failed to maintain proper temperatures of the medication refrigerator, and failed to ensure only Licensed staff have access to medication room keys. These failures have the potential to affect all 65 residents residing in the facility. Findings include: The facility Long Term Care Facility Application for Medicare and Medicaid dated 2/20/24 documents 65 residents reside in facility. 1.) On 2/21/24 at 11:50 AM V8 (Licensed Practical Nurse/LPN) locked the East Hall medication cart and was able to open the second drawer exposing multiple opened and partially used creams and ointments with resident labels on them. This same drawer contained two large pair of scissors, resident labeled medications in boxes, pens, and other items. The top edge of the third drawer, where dozens of cards of resident medications are stored, was broken. V8 was able to place her hand through the top of the third drawer to remove a card of medication with the medication cart still locked.…

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

Based on observation, interview, and record review, the facility failed to provide the services of a clinically qualified director of food and nutrition services. This failure has the potential to affect all 65 residents residing in the facility. Findings include: On 2/20/24 at 9:14 AM, V4 (Dietary Manager) was actively managing kitchen personnel and directing the food sanitation and preparation activities in the facility's kitchen. On 2/20/24 at 9:14 AM, V4 stated, I am the dietary manager. I have a CFM (Certified Food Manager, sanitation) certificate. I don't have a CDM (Certified Dietary Manager),but I am just now looking around to see which school I can enroll in to do the courses. V4 continued, I started as the Dietary Manager here in June of 2022. I am sure we got the same tag (citation) on our survey last year. V4 further stated, I don't have any military experience. I did have a food sanitation (cooking) certificate before 1990, but no, never had any long courses of 90 hours before that. V4's certificate for Certified Food Manager was dated as valid until 10/27/26. 02/21/24…

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.

Based on observation, interview, and record review, the facility failed to maintain food storage to protect food quality and potential for cross contamination. These failures have the potential to affect all 65 residents residing in the facility. Findings include: On 2/20/24 at 9:20 AM, in the facility's dry storage room was an opened, partially filled 10-pound plastic bag of uncooked pasta. This bag of pasta was not dated as to when it was opened, nor was it dated as to when to use it by before it would need to be discarded. There was an opened, partially filled metallic bag of bread croutons which was likewise undated as to when it was opened or needed to be used by. There were two 5-gallon plastic bins, one containing bulk flour and one containing bulk sugar which had the lids open. These bins were sitting on a lower wooden shelf directly underneath a second wooden shelf, potential exposing these bulk items to contamination from the shelving and other food items stored above them on the upper shelf. On 2/20/24 at 9:20 AM, V4 (Dietary Manager) stated, They (kitchen staff) are…

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 required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 65 residents residing in the facility. Findings Include: The Quality Assurance Performance Improvement (QAPI) Plan dated 9/15/23 documents the facility Quality Assessment & Assurance (QAA) Committee consists of facility leadership including the Infection Preventionist. The QAA committee should meet at least quarterly and will be responsible for developing and implementing appropriate plans of action to correct identified quality deficiencies. On 2/22/24 V1 Administrator provided four Quality Assessment and Assurance (QAA) committee meeting sign-in sheets for the previous year's worth of QAA meetings. The January through March 2023 and the April through June 2023 Quality Assessment and Assurance (QAA) meeting sign-in sheets document the facility's Infection Preventionist did not attend. On 2/22/24 at 3:15 PM V1 (Administrator) confirmed there was no Infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their Infection Prevention and Control Program policy to investigate and report a facility communicable infectious disease outbreak to the local health department/or state agency. This failure has the potential to affect all 65 residents residing in the facility. Findings include: On 2/20/24 at 9:07 am during initial tour of the facility, R36 had an infection control set-up of Personal Protective Equipment outside her bedroom door and a red barrel for contaminated linen in R36's room. A sign was posted on R36's door that documents, Enhance Barrier Precautions. On 2/20/24 at 9:19 am V7 (Certified Nursing Assistant/CNA) stated (R36) might be on infection control precautions because she has had UTI's (Urinary Tract Infections). She (R36) may be still on isolation for vomiting and diarrhea. Several people had diarrhea and vomiting a couple weeks ago, on all units and were all put on isolation. On 2/20/24 at 10:20 am V8 (Licensed…

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 ensure resident rights were maintained by failing to include five residents in their care plan meetings. This failure affected six of six residents (R9, R16, R30, R42, R45 and R60) reviewed for care planning/resident rights on the sample list of 50. Findings include: On 02/21/24 at 9:00 am V11 (Activity Director) arranged a resident group meeting, and provided the list of residents that will attend. V11 confirmed the following residents are alert and oriented and are scheduled to participate in the group meeting: R9, R16, R30, R42, R45 and R60. On 02/21/24 at 11:00 am, during resident council group meeting R9, R16, R30, R42, R45 and R60 stated they have never been invited to a care plan meeting and did not know there was a meeting they could contribute care requests. 1. R9's Care Plan documents: Last Care Plan Review Completed: 01/07/2024. R9's Minimum Data Set, dated [DATE] documents Brief Interview of Mental Status score of 14 out of 15, indicating 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 and interview, the facility failed to protect resident dignity by serving residents seated at the same dining table at different times. This failure affects two residents (R12 and R23) out of 22 reviewed for dining on the sample list of 50. Findings include: On 2/20/24 at 12:50 PM, R12 was served the noon meal. Seated at the same table with R12 was R23, who did not get her meal served until 1:13 PM. On 2/21/24 at 11:20 AM, V4 (Dietary Manager) stated, I was aware that the residents seated at the table were not served around the same time yesterday. We had one of our cooks who forgot to bring out the rolls and we were behind and trying to rush. That is not how I usually try to serve the meals and yesterday was just unacceptable.

Based on interview and record review, the facility failed to update a resident's medical record to reflect a resident's wishes for life sustaining treatment including cardio-pulmonary resuscitation. This failure affects one resident (R26) out of one reviewed for advanced directives on the sample list of 50. Findings include: R26's Nurses Notes dated 6/28/23 document R26 was admitted to the facility on this date, 6/28/23. R26's POLST (Practitioner Ordered Life Sustaining Treatment) form dated 6/28/23 documents R26 selected and signed her desire and election to not receive life sustaining treatment including cardio-pulmonary resuscitation. R26's Nurses Notes dated 2/3/24 document R26 was sent to the local emergency room with irregular heartbeat and low oxygen saturation reading of 49 percent. R26's Nurses Notes on this same date document the nurse in the emergency room called a report to the facility nurse to inform that the hospital was sending R26 back to the facility because R26 had a DNR (Do Not Resuscitate) order. Nurses Notes on this same date document R26's (Power of attorney,…

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 recognize and report injuries of unknown origin for one (R41) out of two residents reviewed for injuries of unknown origin in a sample of 50 residents. Findings include: R41's Diagnoses List includes medical diagnoses dated 05/19/21 as follows: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance Psychotic Disturbance, Mood Disturbance and Anxiety. On 02/20/24 at 11:28 am, R41 was seated in a wheelchair next to the dining table. R41 had a dressing on R41's right wrist that extended up R41's forearm. R41 stated she has no idea what happened to her arm. R41's Medication Administration Record dated 2/23/24 does not document R41 received administration of an anticoagulant or aspirin medication. R41's Health Status Note dated 2/20/2024 at 06:20 am documents the following: Note Text: CNA (unidentified) notified writer of observed skin tear to the back of resident hand. Observed a dry edge skin tear with fresh opening to the bottom of the tear. Skin tear is 4 (four) inches long. Cleans (cleaned) with a wound…

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 and monitor an injured Left Foot for one resident (R9) out of one resident reviewed for skin/injuries in a sample list of 50 residents. Findings include: R9's undated Face Sheet documents medical diagnoses of Back Pain, Spinal Stenosis, Morbid Obesity, Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Pain in Left Ankle and Joints of Left Foot, Permanent Atrial Fibrillation, Peripheral Vascular Disease and Chronic Diastolic Heart Failure. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact. This same MDS documents R9 requires maximum assistance for bathing, dressing and moderate assistance for transfers and toileting. R9's Care Plan does not include a focus area, goal nor interventions for potential for alteration in skin. R9's Physician Order Sheet (POS) dated February 2024 documents a physician order starting 9/15/23 for elastic bandage wraps on bilateral lower…

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 administer medications per physician order for two of five residents (R30, R12) reviewed for medication administration on the sample list of 50 residents. The facility had four medication errors out of 25 opportunities for error resulting in a 16% medication error rate. Findings include: 1.) R30's Minimum Data Set (MDS) dated [DATE] documents R30 as cognitively intact. R30's Physician Order Sheet (POS) dated February 2024 documents physician orders for Lactobacillus tablet Give two capsules via Gastrostomy Tube (G-Tube) every morning and at bedtime for gut health, Omeprazole 20 milligrams (mg)/10 milliliters (ml). Give 10 ml per G-Tube twice daily. This same POS documents a physician order to give Sinemet 25-100 mg, give four tablets, four times per day, one- and one-half hours before a meal. On 2/21/24 at 8:30 AM, V12 (Licensed Practical Nurse/LPN) administered R30's Lactobacillus, one capsule via Gastrostomy Tube (G-Tube). V12 prepared 20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their Antibiotic Stewardship policy for one (R9) resident out of two residents reviewed for Antibiotic Stewardship in a sample list of 50 residents. Findings include: The facility policy titled 'Antibiotic/Anatomic Stewardship Program' effective 11/28/17 documents the facility utilizes the McGeer's Criteria for determining if an infection meets criteria for treatment with an antibiotic. R9's undated Face Sheet documents medical diagnoses of Back Pain, Spinal Stenosis, Morbid Obesity, Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Pain in Left Ankle and Joints of Left Foot, Permanent Atrial Fibrillation, Peripheral Vascular Disease and Chronic Diastolic Heart Failure. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as cognitively intact. This same MDS documents R9 requires maximum assistance for bathing, dressing and moderate assistance for transfers and toileting. R9's Physician Order Sheet (POS)…

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 educate residents about the risks and benefits of receiving a pneumonia vaccine and failed to offer the vaccine to residents. This failure affects two residents (R26 and R40) out of five reviewed for immunizations on the sample list of 50. Findings include: 1. R26's Nurses Notes dated 6/28/23 document R26 was admitted to the facility on [DATE]. R26's immunization record (undated) did not include any record of receiving nor declining any pneumococcal vaccine including the pneumococcal conjugate vaccine (PCV) 13 or 20, nor a pneumococcal polysaccharide vaccine (PPSV) 23. On 2/22/24 at 1:42 PM, V3 (Infection Preventionist) stated, I do not find any record of a pneumonia vaccine for (R26). She came from (another long-term care facility) and we would usually receive that information from them and record it in their record here. I am looking at her admission paperwork and I only see the record for her covid and influenza vaccines. 2. R40's Nurses Notes dated…

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 that a resident's (R1) representative was notified in a timely manner, of retention of urine that required an invasive device insertion to relieve pain from excessive urine retention, and critical laboratory results. This failure affected one of three residents (R1) reviewed for notification of change in condition on the sample list of five. Findings include: 1.) R1's Health Status Note dated 12/13/2023 at 07:30 am documents the following: Note Text: Res (resident, R1) crying, clutching abdomen, bladder distended at this time. Catheterized (urinary), 1600 mL (milliliters) urine drained. Light/clear amber in color. Left catheter (urinary indwelling) in place, 16 Fr (size 16 French). Called and reported to (V14 Nurse Practitioner). Order (Physician order to keep brand name, urinary indwelling catheter) in place. See POS (Physician Order Sheet) for order details. There was nothing documented in R1's medical record that V8 (R1's Power of Attorney) was notified of R1's urinary retention or that a urinary indwelling…

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 accurately encode a resident's health status on the Resident Assessment Instrument (Minimum Data Set) regarding falls. This failure affects one of three residents (R1) reviewed for falls/resident assessments on the sample of five. Findings include: R1's Face Sheet documents R1's initial admission to the facility occurred on 11/22/23. R1's first fall risk assessment on admission [DATE] documents R1 had 1-2 falls in the past three months. R1's Minimum Data Set (MDS) dated [DATE] inaccurately coded section J1700 by checking the letter B, which documents R1 had no falls in the past 2-6 months prior to admission [DATE]). On 12/29/23 at 8:50 am V2 (Director of Nursing/DON) reviewed R1's medical record and confirmed R1's incongruent fall information. V2 stated (R1) had falls prior to admission. She fell at home and ended up in the hospital. The MDS clearly should have been coded correctly to indicate that she had a fall at home. Her fall risk assessment 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, record review, and interview the facility failed to implement targeted fall intervention for a two resident (R1 and R4) at risk for falls, with a history of falls. R1 and R4 are two of three residents reviewed for falls on the sample list of five. Findings include: 1.) R1's Minimum Data Set, dated [DATE] documents R1's Brief Interview of Mental Status score as three out of a possible 15, indicating severe cognitive impairment. R1's Fall Risk assessment dated R1's first fall risk assessment on admission dated 11/22/23 documents R1 had 1-2 falls in the past three months and is at risk of falls. R1's Care Plan dated 11/30/23 documents the following: I am at risk for falls r/t (related to) dx (diagnoses) of polyarthritis, dementia, CHF (Congestive Heart Failure), Date Initiated: 11/22/2023. Ensure that (the) resident is wearing nonskid footwear when ambulating or mobilizing in w/c (wheelchair). The facility Incident by Incident list dated 9/27/23- 12/27/23 documents R1's un-witnessed 12/02/23…

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

Based on interview and record review the facility failed to maintain a complete and accurate medical record for one of five residents (R4) reviewed for accuracy of medical records on the sample list of five. Findings include: The facility Incident by Incident list dated 9/27/23- 12/27/23 documents R4's un-witnessed 12/1/23 at 7:15 am as follows: Predisposing Situation Factors: Recent Room Change, admitted within Last 72h, Side Rails Up, Ambulating without Assist, Improper Footwear, Restless, (and) Behavior Symptoms. R4's FALL-INITIAL OCCURRENCE NOTE dated 12/1/2023 at 10:57 am documents the following: Late Entry: Fall Description: Resident had an un-witnessed fall 12/01/2023 at 12:00 AM (actual fall 12/01/23 at 7:15 am), Location of Fall: room (Room), Resident (R4) was self-transferring from bed to recliner forgetting she wasn't at home, holding on the rail of bed and slipped off the bed to floor on her bottom. Denies hitting her head was very anxious., on (sic) 12/01/2023 (at) 12:00 AM (fall had not occurred yet, fall 7:15 am). Resident statement (if applicable): She (R4) states…

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

Based on observation, interview, and record review the facility failed to implement physician orders for compression stockings for one (R1) of three residents reviewed for accidents in the sample list of three. Findings include: The facility's Report to Illinois Department of Public Health documents on 7/30/23 at 9:45 AM R1 sustained a laceration of the right leg during a transfer. R1 was sent to the emergency room and received 10 sutures. This report documents the cause of R1's laceration was R1 bumped R1's right leg on the bracket of R1's wheelchair during a transfer. R1's emergency room Provider Note dated 7/30/23 at 11:38 AM documents R1 presented with a 4-centimeter laceration of the right lower leg that required 10 sutures to close. R1 reported the laceration occurred when staff transferred R1 from the wheelchair. R1's Care Plan with revised dated 8/14/23 documents R1 is at risk for impaired skin integrity and R1 received a skin tear to the lower extremity during a transfer. R1's Order Summary Report 8/14/23 document orders for Apixaban (anticoagulant) give 2.5 milligrams…

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

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 48 residents residing in the facility. Findings include: On 1/17/2023 at 10:25AM, V4 (Dietary Manager) was actively supervising dietary operations in the facility kitchen during resident meal preparations. V4 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Resident Census and Conditions of Residents report (1/17/2023) documents 48 residents reside in the facility.

Based on record review and interview, the facility failed to offer pneumonia and/or influenza vaccines to three (R20, R40, R42 ) of five residents reviewed for Immunizations in the sample list of 25. Findings include: 1. R20's Physician Order Sheet (POS) dated January 2023 documents that the facility may administer Influenza and Pneumonia vaccines unless contraindicated. This same POS does not document R20 having any allergies to the above vaccines or their components. R20's Immunization Sheet (current) documents R20 receiving an influenza vaccine on 10/19/21 but does not document R20 receiving this vaccine in 2022. This same Immunization Sheet also documents R20 receiving Pneumococcal Polysaccharide Vaccine 23 (PPSV23) on 12/20/05 and never having received PCV15 (Pneumococcal Conjugate Vaccine 15) or PCV20 (Pneumococcal Conjugate Vaccine 20) per CDC (Center for Disease Control) recommendations. R20's Medical Record does not have documentation that the Influenza Vaccine for 2022 was offered and/or declined. R20's Medical Record does not document R20 having been offered and/or…

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