Fair Havens Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer medications as ordered for two of six residents (R2, R49) reviewed for medication administration in the sample list of 49. This failure resulted in 8 errors out of 25 opportunities (a 32% medication error rate). Findings include:1.) On [DATE], from 11:28 AM to 11:45 AM, V4, Licensed Practical Nurse, prepared and administered the following oral medications to R2: Hydralazine Hydrochloride (cardiac medication) 50 milligrams (mg), Potassium Chloride 10 milliequivalents, Torsemide 20 mg, and Oxybutynin Chloride Extended Release 15 mg. V4 stated that R2's blood glucose was 150 and that R2 would receive 2 units (u) of insulin. R2's lispro insulin was not in its original box and was not labeled with a dispensed or opened date. The vial had a handwritten date of [DATE] next to the expiration/discard date. V4 administered 2 units of lispro insulin into R2's abdomen.V4 informed R2 that these were R2's morning medications. At 11:47 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.

Based on observation, interview, and record review the facility failed to ensure medications are administered timely resulting in significant medication errors for three of five residents (R2, R49, R56) reviewed for medication errors in the sample list of 49. Findings include:1.) On 12/08/2025, from 11:28 AM to 11:45 AM, V4, Licensed Practical Nurse (LPN), prepared and administered R2's oral medications, including Hydralazine Hydrochloride (cardiac medication) 50 milligrams (mg). V4 told R2 these were R2's morning medications. At 11:47 AM, V4 used an electronic blood pressure cuff to obtain R2's blood pressure, which was 162/121 in the left arm and 170/100 in the right arm. V4 administered Metoprolol Tartrate 50 mg at 12:00 PM. At 1:38 PM, V4 stated medications are to be given within one hour before or after the scheduled time.R2's December 2025 Medication Administration Audit Report (MAAR) documents the following: Hydralazine 50 mg is scheduled three times daily at 9:00 AM, 1:00 PM, and 9:00 PM. On 12/08/25, the morning dose was administered at 11:38 AM, and the afternoon dose was…

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

Based on observation, interview, and record review the facility failed to ensure medications were not expired, discard discontinued medications, ensure multiuse vials were labeled with opened dates, maintain medications in their original packaging, and lock the medication cart when not in use. This failure affects five of six residents (R2, R17, R49, R51, R14) reviewed for medication storage in the sample list of 49. Findings include: The facility's Storage of Medications policy dated 10/27/14 documents that medication carts are to be locked when unattended to prevent unauthorized access to medications. Medications must be dispensed in containers that meet regulatory requirements, and nurses may not transfer medications from one container to another. Outdated and expired medications should be removed from inventory and properly disposed of. Medication storage conditions should be checked on a monthly basis. Certain multidose injection vials require a shorter expiration date than the manufacturer's expiration date to ensure medication potency. Opened vials must be labeled with 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 observation, interview, and record review the facility failed to implement appropriate infection control practices during medication administration, failed to wear appropriate (Personal Protective Equipment (PPE)) when caring for residents on EBP or Contact Precautions, failed to post proper signage for residents requiring EBP or Contact Precautions, failed to ensure PPE supplies were readily available outside resident rooms for ten (R2, R7, R8, R18, R21, R30, R49, R56, R64, R89) out of ten residents reviewed for Infection Prevention and Control on a sample list of 49. These failures have the potential to compromise resident safety and increase the risk of transmission of infectious agents. Findings include: 1.) R56's Electronic Medical Record (EMR) contained culture results dated 11/20/25 documenting that R56's urine was positive for Escherichia coli (Extended Spectrum Beta-Lactamase [ESBL]) and Providencia stuartii (P. stuartii). R56's Physician Order Sheet, dated November 2025, documented an order…

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 reassess blood pressure with a manual cuff to verify accuracy and report an elevated blood pressure to the physician for one of six residents (R2) reviewed for medication administration in the sample list of 49. Findings include:The facility's Acute Changes in Condition Clinical Protocol, dated August 2008, documents that the nurse will monitor and report any changes in a resident's condition to the physician, including assessment of vital signs. The policy further documents that, prior to contacting the physician, the nurse should make pertinent observations and collect appropriate information to report, and that staff will document monitoring and responses to treatment.On 12/08/2025 at 11:47 AM, V4, Licensed Practical Nurse, used an electronic blood pressure cuff to obtain R2's blood pressure of 162/121 from the left arm and 170/100 from the right arm. V4 administered Metoprolol Tartrate 50 mg at 12:00 PM.R2's active care plan documents diagnoses of atrial fibrillation, hypertension, and heart failure and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pressure relieving interventions for one of two residents (R49) reviewed for pressure ulcers in the sample list of 49. Findings include: The facility's Prevention of Pressure Ulcers policy, dated August 2008, documents that pressure ulcers form when residents remain in the same position for extended periods, causing increased pressure and decreased circulation to affected areas. The policy further documents that pressure ulcers can worsen due to continual pressure. Interventions include changing positions at least every two hours when in bed and every hour when in a chair.On 12/07/2025 at 8:13 AM, R49 was observed in bed asleep, lying on his back on an air mattress. On 12/07/2025 at 1:04 PM, R49 was again observed lying in bed on his back. R49 stated that he has sores on his buttocks that began while hospitalized and that his biggest pet peeve is that staff do not reposition him often enough or place him on his side.On 12/08/2025…

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.

Based on observation, interview, and record review the facility failed to administer gastrostomy tube feeding per physician's order and facility policy for one of one resident (R7) reviewed for gastrostomy tubes in the sample list of 49. Findings include: The facility's Gastric Tube Feeding via Syringe (Bolus) policy dated August 2008 documents verify the physician's order for product volume and review the resident's care plan. Attach the syringe without plunger to the tube and pour the prescribed amount of feeding into the syringe and allow to flow by gravity. Add the prescribed amount of water. Clamp tube and detach syringe. R7's Physician Order dated 10/17/25 documents to administer Jevity 1.5 Calorie 300 milliliter (ml) bolus feedings every six hours. On 12/8/25 at 1:12 PM V4 Licensed Practical Nurse stated R4 gets 600 ml of feeding. V4 used a syringe and plusher to push 600 milliliters of Jevity 1.5 cal into R7's gastrostomy tube. Between drawing up each syringe of feeding with one hand, V4 used her other hand to attempt to hold R7's gastrostomy tube, then laid R7's unclamped…

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 offer and administer pneumococcal vaccinations for two (R21,R53) of five residents reviewed for immunizations on a sample list of 49. This deficient practice has the potential to place residents at an increased risk for developing pneumonia. Findings include:R21's Minimum Data Set (MDS) dated [DATE] documents that R21's thought process is moderately impaired.On 12/10/2025 at 10:32 AM, R21 stated she does not remember whether the facility asked her if she wanted the pneumonia vaccine at the time of admission. R21 stated she would like to receive the pneumonia vaccine if the facility offered it.On 12/10/2025 at 10:58 AM, V28 (R21's family member and Power of Attorney [POA]) stated she was present with R21 at the time of admission. V28 stated she recalled the facility offering the influenza and COVID-19 vaccines on admission, but not the pneumonia vaccine. V28 stated it would be beneficial for R21 to receive the pneumonia vaccine if possible.R21's undated…

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

Based on observation, interview and record review the facility failed to maintain a clean, safe, sanitary environment to prevent cross contamination of food service areas and cooking utensils, free of German cockroach infestation. This failure has the potential to affect all 95 residents that reside in the facility. Findings include:On 11/21/25 at 1:50 PM V26, Housekeeper/Laundry stated We clean the rooms (resident rooms) every day and as needed. There have been bugs in residence rooms on occasion. That is not the issue. The issue is the kitchen and dining room. Let me show you the staff lounge. That wall backs up to the kitchen and is just adjacent to the steam table line where all the resident's food is plated (confirmed observation of staff lounge location). I haven't heard any resident complain that they had a bug in their food. But I can tell you they complain about bugs in the dining room, often. Walk down here and I can show you the staff lounge. You won't believe it. V26 Housekeeper entered the staff lounge door which was directly next to the steam table food service line.…

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

Based on interview and record review the facility failed to ensure a qualified licensed nurse administered medication to an undetermined number of residents. This failure has the potential to affect all 95 residents in the facility.Findings include:V39's Health Care Worker Background Check date 01/26/16 documents V39 is eligible to work as Certified Nursing Assistant (CNA).The facility undated Certified Nursing Assistant job description does not include administration of resident medication.The employee corrective action report dated 11/21/25 and signed by V2, Director of Nursing and V39, Certified Nursing Assistant documents Employee will not pass (administer) medications without having the proper license to do so.On 11/21/25 at 12:20 pm V39, Certified Nursing Assistant (CNA) stated I am an LPN (Licensed Practical Nurse) Student, but I don't have my Licensed yet. I am not done with school. I am not supposed to give the residents medication. I did help a nurse pass medication one day. She was busy, so I helped. I think it was sometime in July or August. (V9, Licensed Practical…

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

Based on observation, interview, and record review the facility failed to maintain an effective pest control program by failing to prevent cockroaches in the kitchen and serving/steam table area. This failure has the potential to affect all 95 residents in the facility.Findings Include:On 11/21/25 at 2:06pm Policy and Procedure: Pest Control Policy and Procedure dated 2/3/2022 documents this facility shall maintain an effective pest control program.On 11/19/25 at 9:40 AM the floor areas throughout the resident meal serving/steamtable area adjacent to the kitchen was observed with remnants of pest/cockroaches on glue boards and remnants/carcasses of dead cockroaches were also noted on the back counter/back splash area.On 11/29/25 at 1:45pm R4 stated on 11/13/25 at an unknown time R4 felt something on the left leg, when R4 pulled the covers back R4 saw a cockroach crawling on R4's left leg. R4 further stated R4 witnessed a cockroach crawl out from under the heating/AC unit in the room. R4 stated R4 was unable to kill cockroach and the cockroach crawled back under the heating/ac unit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed repeatedly, to provide a dependent resident (R7) showers. R7 is one of six residents reviewed for Quality of Care on the sample list of 35. Findings include:R7's Minimum Data Set (MDS) dated [DATE] documents R7's Brief Interview of Mental status score of nine out of a possible 15, indicating severe cognitive impairment. The same MDS documents R7 had no hallucinations or delusions, and no behaviors verbal or physical towards self or others and has not rejected care during the lookback period of this assessment.The same MDS documents R7 has occasional incontinence of urine and is continent of bowel.The same MDS documents R7 requires Substantial/maximal assistance - Helper does 'MORE THAN HALF' the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. (for) Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to maintain a Schedule IV, Controlled substance medication supply in a timely manner for one of sixteen residents (R13) reviewed for medication on the sample list of 35.Findings include:R13's current Diagnoses Sheet documents the following: Schizoaffective Disorder, Unspecified, Major Depressive Disorder Recurrent, Severe with Psychotic Symptoms, Generalized Anxiety Disorder, Auditory Hallucinations, and Insomnia.R13's Physician Order Sheet dated September 1-31, 2025, documents the following medication order: Lunesta (hypnotic, controlled substance) Oral Tablet 2 MG (Eszopiclone), Give 1 tablet by mouth at bedtime related to Schizoaffective Disorder, Unspecified.R13's Minimum Data Set, dated [DATE] documents R13's Brief Interview of Mental Status score as 15, out of a possible 15, indicating R13 has no cognitive impairment.R13's Administration note dated 9/24/2025at 12:09 am, documents the following: Note Text: Lunesta Administration Oral Tablet, 2 MG…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medication as ordered by the physician for one (R4) of 17 residents reviewed for medication administration in a sample list of 35.R4's care plan documents R4 admitted to the facility on [DATE] with diagnoses of Fracture of Right Femur, Chronic Ulcer of Other Part of Right Lower Leg, Chronic Ulcer of Other Part of Left Lower Leg, and Abnormalities of Gait and Mobility.On 12/2/25 at 10:30am record review documents on 10/23/2025 at 2:15pm a physician's order was obtained for Hydromorphone HCl (pain) Oral Tablet 4 MG. Directions are to give 1 tablet by mouth every six hours as needed for pain.On 12/2/25 at 10:45am Record review of the Controlled Drug Receipt/Record /Disposition form documents R4 was administered on the following dates and times at less than six-hour intervals: 11/1/25 at 9:00am and 2:00pm (5hours apart), 11/2/25 at 2:00pm and 2:30pm (30min apart), 11/3/25 at 7:00pm and 11:15pm (4hours 15min apart), 11/4/25 at 09:13am and 1:00pm…

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 repeatedly failed to document administration of medication on the Medication Administration Record for one (R4) of three reviewed for medication administration.Findings Include:The Undated MEDICATION/TREATMENT ADMINISTRATION RECORD POLICY documents It is the policy of this facility that each medication/treatment administered will be promptly documented in the medication record after administration. The policy documents the purpose is to validate residents are receiving drugs and biologicals as ordered by the physician. 9. Documents Nursing personnel administering medication/treatments will abide by all Medical Records Policies.R4's care plan documents R4 admitted to the facility on [DATE] with diagnosis of Fracture of Right Femur, Chronic Ulcer of Other Part of Right Lower Leg, Chronic Ulcer of Other Part of Left Lower Leg, And Abnormalities of Gait and Mobility.On 12/2/25 at 10:30am record review documents on 10/23/2025 at 2:15pm a physician's order was obtained…

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 complete a physician ordered wound treatment for one (R4) of three residents reviewed for treatments in the sample list of 35.Findings Include:The Undated MEDICATION/TREATMENT ADMINISTRATION RECORD POLICY documents It is the policy of this facility that each medication/treatment administered will be promptly documented in the medication record after administration. The policy documents the purpose is to validate residents are receiving drugs and biologicals as ordered by the physician. 9. Documents Nursing personnel administering medication/treatments will abide by all Medical Records Policies.R4's care plan documents R4 admitted to the facility on [DATE] with diagnoses of Fracture of Right Femur, Chronic Ulcer of Other Part of Right Lower Leg, Chronic Ulcer of Other Part of Left Lower Leg, and Abnormalities of Gait and Mobility. On 11/19/25 at 1:40pm R4 was laying in the bed with covers over the bilateral legs.On 11/19/25 at 1:45pm R4…

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 supervision during a shower (R19) and failed to provide supervision outside during smoking (R7) which resulted in falls. R19 and R7 are two of three residents reviewed for falls on the sample list of 35.Findings include:1.) R19's current diagnoses sheet documents the following: Difficulty [NAME], Not Elsewhere Classified, Muscle Weakness (Generalized), Other Lack of Coordination, Need for Assistance with Personal Care and Repeated Falls.R19's Minimum Data Set (MDS) dated [DATE] documents the following: R19's Brief Interview of Mental Status (BIMS) score as 15 out of a possible 15, indicating R19 has no cognitive impairment. The same MDS documents R19 has had two falls with no injury and one fall with minor injuries since the last MDS assessment.R19's Fall-Incident report dated 9/20/25 documents R19 had an unwitnessed fall in the shower. Root cause on the report was determined to be: R19 slipped when standing up from the shower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain a urinary indwelling catheter tube in a secure manner, to prevent pain for one of three residents (R1) reviewed for indwelling urinary catheters on the sample list of 35. Finding include:R1's Physician Order Sheet dated 11/1/25-11/30/25 documents the following: (Name brand - indwelling urinary catheter) Catheter French (type):16F Balloon Size:10cc (cubic centimeters) Dx (diagnosis): Obstructive and Reflux Uropathy.R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status score of 13 out of a possible 15, indicating R1 has no cognitive impairment. The same MDS documents R1 has a urinary indwelling catheter.R1's Care Plan dated 8/25/25 documents the following: (R1) has indwelling Catheter r/t (related/to) dx (diagnoses) obstructive reflux uropathy, urinary retention and is at risk for UTI (Urinary Tract Infection) with HX (history) of UTI.The same Care Plan documents: (R1) will be/remain free from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain a resident room free of odors from urine-soaked clothing. This failure affects one of three resident (R7) review for laundry services on the sample list of 35.Finding include:R7's Minimum Data Set (MDS) dated [DATE] documents R7's Brief Interview of Mental status score of nine out of a possible 15, indicating, severe cognitive impairment. The same MDS documents R7 requires Substantial/maximal assistance - Helper does 'MORE THAN HALF' the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. (for) Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.On 11/23/25 at 6:13 am V34, Housekeeping/Laundry Worker was in the soiled utility room V34 pushed a large cart of soiled laundry out of the room. V34 stated Laundry is picked up on the units at least every…

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

Based on interview and record review, the facility failed to provide timely incontinence care for a resident dependent on staff for hygiene. This failure affects one (R7) of three residents reviewed for Activities of Daily Living in the sample list of eleven. Findings include:The facility's Policy and Procedure: Call Light System (undated) documents it is the policy of this facility to provide a means of communication to meet the needs of each resident. Staff will follow established procedures to respond to the resident's requests and needs. Procedure: Respond promptly when the call light is activated. Identify self, determine the resident's need and turn off the call light. Respond to the residents needs or request and if unable to meet the need, find the staff member who can meet the need.R7's Face Sheet (9/2/25) documents R7 has the following diagnoses: Paraplegia, lack of coordination, weakness, and need for assistance with personal care.R7's Quarterly Assessment (7/23/25) documents R7 is cognitively intact, has bilateral lower extremity impairment, and dependent on staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the dignity of two residents (R4, R2) out of two reviewed for dignity in a sample list of nine.Findings include:1) On 08/04/2025 at 2:30 PM, Employee handbook dated revised [DATE], documents on page 3: We count on you, our employees, to focus on the provision of quality care and excellent services for our residents and to do so with a high level of dignity, compassion, and responsiveness to their physical, medical, and emotional needs. Our residents deserve nothing less than your best each and every day. On 7/28/25, R4's record review documents a Minimum Data Set (MDS) completed on Jun 24, 2025, documents a Brief Interview for Mental Status (BIMS) score of 14. A score of 14 indicates R4 is cognitively intact.On 7/28/25, R4's Care plan record review documents an admission date of 08/25/2023 with diagnosis of Heart Failure, Non-st Elevation (nstemi) Myocardial Infarction, Acute Kidney Failure, Hypokalemia, and Type 2 Diabetes Mellitus without…

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 one resident (R11) from verbal abuse for one of three residents reviewed for verbal abuse on a sample list of nine.Findings Include: Facility Abuse Prevention Program policy effective 10/2022, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The same policy documents Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an Individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure hot food was served to for three residents (R1, R2, R3) out of three reviewed for dietary services in a sample list of nine.Random observations were completed on 7/24/25 through 8/4/25 related to dietary services, during observations the hall tray cart was delivered to the hallway and nursing staff would deliver trays to the residents. The trays contained the afternoon meal on a plate with a cover. No hot plate under the ceramic plate to keep the food warm. The trays also contained cold food and the drinks. On 7/24/25 at 12:00 PM, the lunch food cart was delivered to the 300 hall by kitchen employee, nursing staff did not pass the trays for 12 minutes to residents. On 8/4/25 at 12:07pm the lunch cart was delivered to the 300 hall, nursing staff passed the meals from the cart at 12:18pm. R1's Clinical Census, undated, documents an original admission date of 4/14/22. Minimum Data Set completed on [DATE], documents a Brief Interview for Mental…

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 sufficient linens to ensure a safe sanitary environment for residents. This failure has the potential to affect all 98 residents who reside in the facility. Findings Include: The facility's Daily Census dated 6/2/25 documents a total of 98 residents reside at the facility. On 6/2/25 at 8:50AM, one washing machine was working out of three in the facility and two driers were running and two were broken. In a locked cabinet in the laundry room and on 100 East Hall approximately three dozen each hand towels and washcloths where stored. On 6/2/25 at 8:50AM, V15, Housekeeping Aide stated that most of the time V15 hears the Certified Nursing Assistants asking for more linens and they run out especially on the weekend. On 6/2/25 at 8:55AM, V17, Laundry Aide stated laundry is short staffed with one aide in morning from 6am-2pm and one aide on the afternoon shift from 2-10p. V17 stated she tries to keep up and passes linen every hour and cleans the laundry room every hour, but sometimes V17 can't keep up. On…

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

Based on observation, interview and record review the facility failed to provide showers for five residents (R1, R7, R19, R21, R22) of eight residents reviewed for Activities of Daily Living (ADLs) in a sample list of 24. Findings Include: On 6/2/25 at 12:37PM, the Resident Counsel President, [NAME] President and residents that normally attend Resident Counsel Meetings were at the table in the activities room. R1, R7, R19, R21 and R22 all had food on their shirts, oily appearing hair, and dirt under their nails. R19 had food on his beard. On 6/2/25 at 12:37PM a Resident Council Meeting was conducted with R1, R7, R19, R21 and R22. During this meeting, R1, R7, R19, R21 and R22 stated they have not had showers in the past week, and staff are stating to residents there are no linens. The residents stated there has been no improvement and grievances have been filed after every monthly resident council meeting. R19 stated residents are to get a shower two days a week. All residents present stated they do not receive showers twice a week. R1's Medical Record documents R1's last shower was…

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

Based on observation, interview, and record review, the facility failed to accurately account for controlled medications and document shift to shift controlled medication counts for seven (R3, R4, R5, R9, R15, R16, R22) of seven residents reviewed for controlled medications in the sample list of 24. Findings include: The facility's Medication Ordering, Receiving, and Storage of Controlled Substances policy dated 5/1/14 documents nurses will count controlled medications at the end of each shift, with both the nurse coming on duty and the nurse going off duty counting together. This will be documented and discrepancies will be reported to the Director of Nursing (DON). The facility's Medication Administration policy dated 11/3/14 documents to review the medication and dosage on the Medication Administration Record (MAR) and medication label prior to administering medications, and document administration on the MAR directly after the medication is given. 1.) On 6/2/25 at 10:07 AM the station 3 medication cart was viewed with V20 Licensed Practical Nurse (LPN). The locked compartment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications timely and as ordered and timely reorder medications resulting in significant medication errors for four (R3, R15, R16, R25) of five residents reviewed for medications in the sample list of 24. Findings include: The facility's Medication Administration policy dated 11/3/14 documents the following: Verify the medication and order with the MAR prior to administration, and medications should be administered according to the physician's order. If a current ordered medication is unavailable then contact the pharmacy to obtained from the night box/emergency kit. Administer medications within 60 minutes of the scheduled time, unless otherwise ordered. Record medication administration on the MAR directly after giving the medication. Enter an explanatory note when withholding scheduled medications and notify the physician of consecutive withheld doses. Document the notification and physician response. 1.) R3's May and June 2025 Medication…

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

Based on observation, interview, and record review, the facility failed to ensure controlled medications were stored appropriately and destroy controlled medications when discontinued for two (R3, R15) of seven residents reviewed for controlled medications in the sample list of 24. Findings include: The facility's Medication Ordering, Receiving, and Storage of Controlled Substances policy dated 5/1/14 documents controlled substances will be stored in the medication room separate from non-controlled medications, in a locked container, which will be locked at all times except when accessed with a key or code to obtain resident medications. This policy documents the charge nurse will maintain the keys to the controlled substance medications, and two licensed nurses will destroy controlled medications as soon as possible when discontinued. 1.) R3's Physician Order dated 4/2/25 documents Morphine Sulfate 20 milligrams per milliliter (mg/ml) give 0.25 ml by mouth every hour as needed for shortness of breath or wheezing. R3's Controlled Drug Receipt/Record/Disposition Form dated 4/2/25…

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

Based on observation, interview and record review the facility failed to administer medications according to physicians orders and manufacturer recommendations for five of 15 residents (R1, R2, R3, R4 and R14) reviewed for medication administration on the sample of 15. The facility had five medication errors out of 37 opportunities resulting in a medication error rate of 13.51 percent. Findings include: 1.) R1's February 2025 Physician Order Sheet (POS) documents an order for Flonase Allergy Relief Nasal Suspension 50 MCG (microgram) 2 puffs each nostril one time a day. On 2/14/25 at 5:33 am V10, LPN (License Practical Nurse) administered R1's medication. V10 did not administer R1's Flonase. On 2/14/25 at 9:43 am V11, LPN stated R1 has an order for Flonase but the medication was not available in the medication cart to give. V1, Administrator stated on 2/14/25 at 11:30 AM This is a stock drug the nurse should have gotten the medication out of the stock medications. 2.) R2's February 2025 POS documents an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligram) 1 tablet…

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 their Abuse Policy to thoroughly investigate an allegation of abuse for one residents (R1) and protect residents from the alleged perpetrator until an investigation was completed for 36 of 36 residents (R1-R36) reviewed for protection from abuse in the sample of 36. Findings include: On 12-27-24 at 10:00 AM R1 stated, On 12-17-24 around 7:30 PM V4 (Registered Nurse) threatened and verbally abused me, and I immediately reported feeling threatened and abused to (V1/Administrator-In-Training). (V4) continued to work that night and even came back into my room later and said, I am here to offer an apology. You can either except it yes, or no? I told (V4) to get out of my room and I did not want her taking care of me. On 12-27-24 at 10:40 AM V1 (Administrator-In-Training) stated, I am going to just be honest with you (R1) text me on 12-17-24 and told me (V4) was being rude to him. I called (R1) right away and do not remember exactly what (R1) reported. (R1) may have said he felt threatened by (V4) and did not want (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.

Based on interview and record review the facility failed to implement their Abuse Policy to immediately report an allegation of abuse to the State Agency for one of three residents (R1) reviewed for Abuse in the sample of 36. Findings include: On 12-27-24 at 10:00 AM R1 stated that on 12-17-24 around 7:30 PM V4 (Registered Nurse) threatened and verbally abused R1. R1 stated he immediately reported feeling threatened and abused to V1 (Administrator-In-Training). On 12-27-24 at 10:40 AM V1 (Administrator-In-Training) stated, (R1) text me on 12-17-24 and told me (V4) was being rude to him. I called (R1) right away and do not remember exactly what (R1) reported. (R1) may have said he felt threatened by (V4). I am going to be honest with you. I did not report (R1's) allegation to the state agency. On 12-27-24 at 11:47 AM V4 stated, On 12-17-24 around 7:30 PM (V1) called me while I was at the facility and said (R1) had called (V1) and reported I threatened him. The facility's Abuse Investigations and R1's Electronic Medical Record dated 12-1-24 through 12-27-24 were reviewed and do not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the shower rooms in a homelike and functional condition. This failure has the potential to affect all 102 residents residing in the facility. Findings include: On 12/4/24 at 4:20 PM, the facility's shower room on the 200 hall was in state of disarray. There was a plastic 5 gallon bucket approximately four inches full of hardened cured cement tile mastic with a steel mixing blade stuck inside. There was a pile of one inch square tiles from the demolition of the shower floor. The shower floor had 15 twelve inch square tiles installed with another 15 needing to be installed including the cut tiles to form a border. There was a four foot long 30 inch wide construction roller cart with boxes of the 12 inch tiles. There was an electric cutting tool laying on the floor. There was a two pound [NAME] hammer on the floor. On 12/4/24 at 4:20 PM, V12, Maintenance Director stated the facility had a guy working on the shower room but had not…

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 dishwasher water temperatures at a level to sanitize dish wares. These failures have the potential to affect all 102 residents residing in the facility. Findings include: On 12/4/24 at 4:35 PM, V12, Maintenance Director, operated the facility dishwasher which reached a final rinse temperature of 156 degrees Fahrenheit (F). A second running cycle resulted in a final rinse temperature of 161 F, and a third cycle resulted in a final rinse temperature of 163 F. There was a metal plate on the front of the dishwasher directly below the digital temperature display which informed the user that the final rinse temperature must be 180 F to sanitize dish wares. On 12/5/24 at 10:18 AM, V21 was operating the facility dishwasher to wash the dishes from the residents' breakfast meal. V22, Dietary Manager, present upon request, stated that dishwasher is supposed to wash at a temperature of 150 F, and rinse at 180 F. The first observed cycle of the dishwasher resulted in a final rinse temperature of 168 F. A second…

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

Based on interview and record review, the facility failed to provide the services of a qualified Social Worker for their facility with a bed capacity of 154. This failure affects all 102 residents residing in the facility. Findings include: On 12/17/24 at 11:50 AM, V1, Administrator, stated the facility does not have a Social Worker with a degree and has not had one for a long (undetermined) time. V1 stated the former Social Services Director (V31) does not have a degree. V1 stated as of this past Friday (12/13/24), V31 has been moved to the position of Business Office Manager and there was no one in the vacant Social Services position The facility's Illinois Department of Public Health License dated 12/10/23 documents the facility has a total skilled bed capacity of 154. The facility's current Staff Roster (undated) does not document any person in the position of Social Services. This Roster documents V31 as the Business Office Manager. On 12/18/24 at 8:55 AM, V31, Business Office Manager, stated he was formerly the Social Services Director, a position he started 10/28/24. V31…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to control of dishwasher sewer surges of water, and sink drain sewer water leakage to prevent to infestation of pests. These failures have the potential to affect all 102 residents residing in the facility. Findings include: On 12/4/24 at 4:35 PM, V12, Maintenance Director, while operating the facility dishwasher, noted a live cockroach on the trash can next to the dishwasher. V12 smacked at the roach, knocking it to the floor, and stepped on the cockroach. There were also numerous small flying insects approximately three-sixteenths of an inch long with opaque wings, commonly referred to as sewer flies or fruit flies. These flies were hovering around the drains in the floor around the dishwasher, and along the stainless steel counters where soiled dishes were stationed prior to going through the dishwasher. and landed on the floor. The floor in the dishwasher area, approximately 12…

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 door alarms and computer based door monitoring systems in functional condition to operate as designed. This failure has the potential to affect all 102 residents residing in the facility. Findings include: On 12/4/24 at 3:58 PM, V12, Maintenance Director, stated the facility utilizes a black box system connected through a centralized monitor screen located at the 400 hall nurses station. V12 stated the system is supposed to connect to additional monitors located at each of the facility's other three nurses stations on the 100, 200, and 300 halls. V12 stated the screen will display a floor map of the facility with each door of the facility located by a colored dot on the screen. V12 stated the system was not functioning to emit a sound when a door was opened. On 12/4/24 at 3:58 PM, the black box system monitor screen was black and not showing the floor plan on the screen. V12 manipulated some controls on the system and did get the screen to display the facility floor plan with green dots at each door…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess residents for their smoking status, and failed to accurately encode minimum data sets for tobacco use. This failure affects three residents (R11, R12, R13) out of five reviewed for smoking status on the sample list of 24 residents. Findings include: The facility's (undated) smoking schedule documented R9, R10, R11, R12, and R13 as current smokers. This schedule documents the activity department and laundry department are the staff responsible for supervising resident smokers. On 12/4/24 at 2:20 PM, V10, Activity Director, confirmed the current resident smokers. On 12/4/24 at 2:30 PM, V11, Laundry Aide, confirmed the list of resident smokers. 1. R11's Minimum Data Set, dated [DATE], Section J1300 documents R11 as no current tobacco use. R11's Care Plan dated with the most recent revisions on 12/5/24 and which is informed by the minimum data set, does not document any focus area for smoking. R11's Smoking assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely assess residents for risk of developing pressure ulcers, and to complete pressure ulcer treatments according to physician orders. These failures affect three residents (R4, R5, R6) out of three reviewed for wound care on the sample list of 24 residents. Findings include: 1. On 12/6/24 at 2:30 PM, R6's Braden Scale assessment dated [DATE] was the most recent located in R6's Electronic Medical Record (EMR). R6's Treatment Administration Record (TAR) dated for November 2024 documents R6 had a physician ordered treatment for a pressure ulcer on the sacrum to be completed twice daily. This treatment was not documented as completed on 11/1/24, 11/11/24, 11/12/24, 11/14/24, 11/18/24 and 11/20/24. This TAR documents R6 had physician ordered ointment to be applied to R6's buttocks twice daily which was not documented as completed on 11/12/24, 11/14/24, 11/18/24, and 11/20/24. This TAR documents R6 had a physician ordered treatment to offload (elevate off…

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 full-time Director of Nursing. This failure affects all 109 residents residing in the facility. Findings include: On 11/19/24 at 9:15 am, V1, Administrator stated the facility has not had a full-time Director of Nursing in six months. Throughout the survey, 11/19/24 - 11/22/24, there was no Director of Nursing (DON) working in the facility. The facility CMS-802 Matrix form dated 11/19/24 documents 109 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure a resident's right to dignified care by failing to provide timely incontinence care. This failure affected one of three residents (R7) reviewed for dignity/incontinence care on the sample list of 14. Findings include: R7's Diagnoses list dated 11/07/24 documents the following: Gullian' Barre Syndrome (serious autoimmune disorder that aggressively attacks all nerve cells within the peripheral nervous system, that leads to partial or complete paralysis), Muscle Weakness, Morbid (Severe) Obesity, and Unspecified Abnormalities of Gait and Mobility. R7's Minimum Data Set (MDS) dated [DATE] documents R7's Brief Interview of Mental status score as 15 out of a possible 15, indicating no cognitive impairment. The same MDS documents R7 is frequently incontinent of bladder and always incontinent of bowel. R7's same MDS documents: Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having 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 observation, interview, and record review, the facility failed ensure a resident's right to a clean, safe, comfortable homelike bathroom. This failure affects one of nine residents (R8) reviewed for resident rights/environment on the sample list of 14. Findings include: R8's Minimum Data Set, dated [DATE] documents R8's Brief Interview of Mental Status score as 13, out of a possible 15, indicated no cognitive impairment. On 11/22/24 at 12:25 pm R8's stated I don't see bugs or anything like that. The housekeepers do a good job cleaning my room. The bathroom is a problem. I have to hold my breath every time I go in there. It is bad, check it out. It is filthy. The housekeepers don't go in there either. You know its bad if they can't stand the smell. There is not a garbage can in there or it would probably be worse. I wear a (incontinence brief) in the case I don't make it and leak. Those (soiled incontinence brief) would end up in the garbage, and increase the bad odors. On 11/22/24 at 12:30 pm V23,…

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 report an injury of unknown origin in a timely manner, to the State Agency. This failure affects one of three residents (R1) reviewed for bruises/injury of unknown origin on the sample list of 14. Findings include: The facility Long-Term Care Facility and IID-Serious Injury Incident Report form to Illinois Department of Public Health dated 11/22/24 (five days after the identification of R1's bruise documented below) documents R1's Initial report of R1 had a Serious Injury of Unknown Origin incident (type/bruise not identified) with a date of occurrence as 11/17/24 at 2:32 pm. R1's Minimum Data Set, dated [DATE] documents R1's Brief Interview of Mental Status score as four, out of a possible 15, indicating severe cognitive impairment therefore was not interviewable. R1's Nursing Note dated 11/17/2024 at 1:55 pm, signed by V10, Registered Nurse (RN)documents the following: Late Entry (bruise-11/17/24): Note Text: Res. (Resident) noted to use restroom 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 thoroughly investigate an injury of unknown origin for one of three residents (R1), reviewed for injury of unknown/bruises on the sample list 14. Findings include: R1's Minimum Data Set, dated [DATE] documents R1's Brief Interview of Mental Status score as four, out of a possible 15, indicating severe cognitive impairment, and therefore was not interviewable. R1's Nursing Note dated 11/17/2024 at 1:55 pm, signed by V10, Registered Nurse (RN)documents the following: Late Entry (bruise-11/17/24): Note Text: Res. (Resident) noted to use restroom and sit uncomfortably on toilet, per aide (V9, Certified Nursing Assistant) caring for res; writer assessed res. and noted raised blood blister. Discoloration slightly pink with dark center approx. 1x1 in (one inch long by one inch wide) size. Loose skin noted to inner thighs, area appears to have been between res. and toilet during transfer. Continuing to monitor at this time. POA/MD (V28, Power of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a safe transfer with a mechanical stand lift. This failure affected one of three residents (R2) reviewed for injury of unknown origin/bruises on the sample list of 14. Findings include: R2's Diagnoses sheet last updated 11/14/24 documents the following: Cerebral Infarction, Unspecified, Other Disorders of Meninges, Not Otherwise Classified, Anxiety, Generalized, Repeated Falls, Difficulty Walking, Not Elsewhere Classified, Unsteadiness on Feet, Muscle Weakness Generalized, Other Lack of Coordination, and Need For Assistance With Personal Care. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status (BIMS) score of eight, out of a possible 15, which indicates moderate cognitive impairment. R2's same MDS documents the following: Safety and Quality of Performance - If helper assistance is required because resident ' s performance is unsafe or of poor quality, score according to amount of assistance provided. 01.…

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

Based on interview and record review the facility failed to document the danger of a resident's transfer or discharge would impose on the safety of other residents nor the specific resident needs that cannot be met at the facility. This failure affects one (R1) of three residents reviewed for readmission. Findings Include: On 9/6/2024 at 11:34 PM progress note documents increasing agitation and behaviors by R1. Same note documents that R1 had hit and punched staff, then was transferred to a local hospital by EMS (Emergency Medical Services), police and fire department assisting in the transfer. On 9/6/2024 R1's medical record documents Discharge Return Anticipated MDS (Minimum Data Set) completed, submitted and accepted. On 10/31/2024 at 4:06 PM the nursing home hotline received a complaint that facility refuses to re-admit R1 to the facility. On 11/6/24 at 11:30 AM R1 medical record review does not document why R1 is not being re-admitted to the facility as requested on 10/31/24 by the hospital. The facility Transfer and Discharge policy dated March 2014 documents that 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.

Based on observation, interview and record review the facility failed to employ a Director of Nurses. This failure has the potential to affect all 98 residents residing in the facility. Findings include: The Facility Assessment updated 8/6/24 documents the facility will provide a full time Director of Nursing. On 8/23/24 and 8/30/24 during first, second and third shifts there was no Director of Nursing observed during the survey timeframe. On 8/30/24 at 4:50 PM V1 Administrator in Training (AIT) and V2 Assistant Director of Nurses (ADON) stated the former Director of Nurses stepped down from the DON role. V2 stated the programs that had been previously managed by the DON are now scattered everywhere. V2 ADON stated It would be great if we could hire another DON. All of our programs are not getting the attention they need because we (facility) are all trying to do too many jobs. V1 stated We (facility) do not have an acting DON. We have put advertisements out but not had any luck. The Resident Roster dated 8/23/24 documents 98 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 protect the resident's right to be free from physical abuse by another resident. This failure affects two of three residents (R8, R2) residents reviewed for abuse in a sample list of eight residents. Findings include: The facility Abuse Policy dated October 2022 documents Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual my have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. R8's undated Face Sheet documents R8's medical diagnoses as Left Artificial Knee Joint, Cerebral Infarction,…

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 timely incontinence care for three (R4, R6, R7) of seven residents reviewed for incontinence care in a sample list of eight residents. Findings include: 1.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 requires assistance with transferring, toileting and personal hygiene. On 8/23/24 at 3:45 AM R4 was fully dressed, sitting up in her wheelchair at the nurses station. R4 was observed multiple times from 3:45 AM-7:30 AM self propelling about the facility with no staff intervention. R4 was escorted to the main dining area at 7:30 AM and sat in the main dining area throughout breakfast. On 8/23/24 at 8:12 AM V19 Certified Nurse Aide (CNA) assisted R4 from the main dining area to the nurses station. V19 did not provide incontinence care. On 8/23/24 at 8:21 AM V14 and V20 Certified Nurse Aide (CNA) and V21 Restorative CNA transferred R4 from her wheelchair to her bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one (R4) resident out of seven residents reviewed for incontinence care in a sample list of eight residents. Findings include: R4's undated Face Sheet documents R4's medical diagnoses as Alzheimer's Disease, Difficulty in Walking, Protein-Calorie Malnutrition, Disorientation, Dementia, Need for Assistance with Personal Cares, and Lack of Coordination. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired. This same MDS documents R4 requires assistance with transferring, toileting and personal hygiene. On 8/23/24 at 8:43 AM V22 and V24 Restorative Certified Nurse Aides (CNA's) provided incontinence care for R4. V22 wore gloves to place a washcloth in a tub of soapy water, then used the washcloth to cleanse R4's perianal area, then placed the same contaminated washcloth in a tub of rinse water. V22 then used the same contaminated washcloth to rinse the…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary food storage areas and failed to maintain sanitary food service areas (floors, walls, equipment surfaces). These failures have the potential to affect all 98 residents in the facility. Findings Include: 1. On 8/11/24 at 8:31 AM the kitchen walk-in cooler floor had food debris and packets of unopened butter on the floor. 2. On 8/11/24 at 8:40 AM a fan facing the drain board area was soiled with accumulations of gray colored dust. 3. On 8/11/24 at 8:40 AM the floor areas throughout the kitchen and adjacent dishwashing areas were heavily soiled with accumulations of decomposing food and grease deposits. Thick deposits of dark grease and decomposed food covered all areas of the baseboards and adjacent floor and wall areas of the dishwashing area and kitchen. The drain board area where staff remove clean dishes from the dishwasher was heavily soiled with food particles, dirt and grease deposits. 4. On 8/12/24 at 9:12 AM the food prep table had an open package of butter, miscellaneous empty…

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 resident living spaces and resident rooms were organized, clean, and free of debris, with walls and furniture in good repair. These failures have the potential to affect all 98 residents residing in the facility. Findings Include: The facility's undated Infection Prevention and Control Manual/ Environmental Services/ Housekeeping/ Laundry policy documents the facility shall be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area in the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area. On 8/11/24 and 8/12/24 at 9:15 AM the dining room floors were sticky. The main hallway from the entry way to the conference room was sticky and dirty with multiple small debris items present and food debris and napkins were on the dining room floor. On 8/11/24 during the facility tour, between 10:30 AM and 11:00 AM three bedside tables with peeling, cracking sharp edges were observed in resident rooms. One…

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

Based on observation, interview, and record review the facility failed to maintain an effective pest control program by failing to prevent drain flies and flies in the kitchen area. This failure has the potential to affect all 98 residents in the facility. Findings Include: On 8/11/24 at 8:40 AM the floor areas throughout the kitchen and adjacent dishwashing areas were heavily soiled with accumulations of decomposing food and grease deposits. Thick deposits of dark grease and decomposed food covered all areas of the baseboards and adjacent floor and wall areas of the dishwashing area and kitchen. The drain board area where staff remove clean dishes from the dishwasher was heavily soiled with food particles, dirt and grease deposits. Live drain flies and flies were observed in the area of the mechanical dishwasher. On 8/12/24 at 9:12 AM the floors remained as previously stated with live drain flies and flies present. On 8/12/24 at 9:12 AM the garbage cans in the kitchen area were full and uncovered. Live flies were observed in the food prep area. V7 Dietary Manager stated maintenance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect the resident's right to a dignified existence by failing to knock and gain permission before entering a resident's room and by failing to provide timely care. These failures affected five of five residents (R36, R4, R19, R40 and R78) reviewed for Dignity on the sample list of 39. Findings Include: The facility's Resident Rights Protocol for All Nursing Procedures policy dated August 2008 documents residents have the right to dignity and respect. When staff needs to enter a resident's room, the staff must first knock and gain permission before entering the resident's room. The staff must also introduce themselves if the resident is unfamiliar with them and explain the reason for their visit. 1. R36's Medical Diagnoses list dated August 2024 documents R36 has Cataracts and Anxiety. R36's Minimum Data Set, dated [DATE] documents R36 is cognitively intact. On 8/11/24 at 10:30 AM V8 Licensed Practical Nurse stated R36 recently 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.

Based on observation, interview and record review the facility failed to properly clean and maintain a Continuous Positive Airway Pressure (CPAP) mask and failed to maintain and store respiratory equipment in a clean sanitary manner, off the floor and failed to date respiratory equipment when changed. These failures affect four of six residents (R14, R34, R37, R41) reviewed for respiratory/oxygen on the sample list of 39. Findings Include: The facility's Departmental (Respiratory Therapy) Prevention of Infection Policy with a revision date of August 2008 documents the following: Change pre-filled humidifier when the water level becomes low. Change the oxygen cannula and tubing every seven (7) days, or as needed. Keep the oxygen cannula and tubing in a plastic bag when not in use. 1. R14's Physician Order Sheet (POS) dated August 2024 documents an order for a Continuous Positive Airway Pressure (CPAP) mask applied at 19 millimeters of water (mmH2O) at bedtime and remove in the morning. There is no order to clean the CPAP mask. On 8/11/24 at 10:42 AM R14's Continuous Positive Airway…

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 observations, interview, and record review the facility failed to ensure a resident was deemed appropriate to self-administer medications before leaving medications unattended for residents to self-administer. This failure affected two of two residents (R72, R90) reviewed for self-administration of medications in the sample list of 39. Findings Include: The Medication Administration Policy dated March 2014 documents the same licensed nurse or QMA (Qualified Medication Aides) who prepare the medications shall also administer those medications to residents for whom they are ordered. The same policy documents residents will be positively identified (i.e. arm band, facial recognition, face sheet photograph, Medication Administration Record photograph, confirmation of identity from another direct care provider) prior to medication administration and shall not be left alone until the medication is consumed or refused. 1. On 8/11/24 at 8:35 AM V10 Registered Nurse entered R72's room with a medication cup containing several unidentified medications. V10 then set the medication cup…

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

Based on interview and record review the facility failed to notify the physician and dietician of a change in condition (significant weight change) for one of one resident (R10) reviewed for weights on the sample list of 39. Findings Include: The facility's undated Weight Assessment and Intervention Policy documents any weight change of greater than five pounds within 30 days will be retaken for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The facility's undated Notification Of Resident Change In Condition Policy documents a licensed nurse shall promptly inform the resident, consult the resident's physician, notify the resident's legal representative or an interested family member of a significant change in the resident's physical, mental or psychosocial status. For example a deterioration in health, mental or psychosocial status. The same policy documents a clinical change in condition is determined by resident visualization, medical record review, clinical assessment findings…

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

Based on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by another resident. This failure affects two of three residents (R72, R253) reviewed for abuse in sample list of 39. Findings Include: The facility's Abuse Prevention Program dated October 2022 documents the facility affirms the right of it's residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. One way this will be done is by identifying occurrences and patterns of potential mistreatment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individuals' age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm or saying things to frighten a resident. R72's Care Plan dated 6/5/2024 documents R72 is alert and oriented. The same Care Plan documents R72 has a behavior problem…

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

Based on interview and record review the facility failed to submit information for Preadmission Screening and Resident Review (PASARR) for a Level I evaluation for one of two residents (R2) reviewed for PASARR on a sample list of 39. Findings Include: The facility's undated admission Policy documents all potential admissions will have participated in the Pre-Screening process or will have wavered rights for Medicaid funds for one year, or be approved as an emergency admit by the PASARR agency. The Facility Census Report dated 8/14/24 documents R2's admission date was 3/26/21. R2's Medical Diagnoses List dated August 2024 documents R2 is diagnosed with Delusional Disorder. On 8/12/24 at 11:46 AM V6 Social Service Director stated that no Level I or Level II PASARR had been completed for R2.

Based on observation, interview, and record review the facility failed to complete dressing changes as ordered by the physician for one of four residents (R90) reviewed for wounds in the sample list of 39. Findings Include: The facility's Pressure/Skin Breakdown-Clinical Protocol policy dated January 2017 documents, The Physician will authorize pertinent orders related to wound treatments, including pressure redistributing surfaces, wound cleansing and debridement, dressings and topical agents. The facility nursing staff will carry out treatments as ordered by Physician. R90's Physician Order dated 7/16/24 documents Cleanse R (right) medial foot and R heel with wound cleanser/NS (Normal Saline), pat dry, apply gauze moistened betadine to wound beds, cover with (padded dressing), wrap with (gauze wrap), and secure with retention tape. Every shift (twice daily) for wound care. On 8/11/24 at 9:45 AM R90's right foot wound dressing was dated 8/9/24. The dressing was visibly soiled with a dark brown substance. On 8/11/24 at 10:15 AM V4 Wound Nurse stated R90 is supposed to have 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 observation, interview, and record review, the facility failed to provide adequate linens including; towels, washcloths, and bed sheets, and failed to mop dirty resident room floors for four (R1, R2, R3, R4) of four residents reviewed for a clean and homelike environment. Findings include: The undated facility provided Laundry Services Policy documents it is the policy of this facility to provide and in-house laundry service for linens and resident personal laundry in a safe and sanitary manner. Additionally, the laundry service will maintain sufficient inventory of clean linen and personal laundry in good repair to meet the needs of the residents. The undated facility provided Housekeeping Services Policy documents it is the policy of this facility to maintain a clean, order free, comfortable and orderly environment in all healthcare and public areas, which meet the sanitation needs of the facility and residents' rights for a safe, clean, comfortable home-like environment. The department shall…

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 keep accurate measurements of resident wounds and skin conditions. This failure affects two residents (R2, R4) out of four reviewed for wound care on a sample of five. Findings include: Policy for Measurement of Alterations in Skin Integrity, dated January 2017, states: 1. At first observation of any skin condition, the charge nurse or treatment nurse is responsible to measure and/or describe skin condition in the clinical record. 2. All measurements will be recorded in centimeters. All wounds/ulcers (i.e. pressure, arterial, diabetic, venous) will be measured weekly and results recorded in the clinical record. 1. R2's Census Detail and Minimum Data Set List (undated) documents R2 was originally admitted to the facility 08/31/2023. R2's current Diagnosis List (undated) documents R2 experiences medical diagnoses including Abnormalities Of Gait And Mobility, Paralysis, Paralytic Gait, Weakness, Need For Assistance With Personal Care, Muscle Weakness (Generalized), Moisture-associated skin damage (MASD). R2's wound assessment…

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 protect the resident's right to be free from sexual abuse by another resident for two (R10, R11) of four residents reviewed for abuse on the sample list of 8. Findings include: R10's Care Plan, with a revision date of 6/6/24, documents R10 is alert and oriented. This Care Plan documents R10 has a diagnosis of Cerebral Palsy and requires staff assistance to transfer out of bed and to turn and reposition in the bed. R11's Care Plan, with a revision date of 4/21/24, documents R11 has a diagnosis of Dementia and has impaired thought processes and impaired decision making. This care plan documents R11 has the ability to transfer self from the bed to the wheelchair. On 6/21/24 at 9:56 AM, R10 stated, (R11) came over to my bed and pulled out her breast, and asked me if I wanted to have i,t and I told her no and that I don't do that. R10 stated this happened about a week ago. R10 stated she told a Certified Nurse's Assistant (CNA) about it. R10 stated she is not sure who the CNA was. R10 stated the CNA took R11 back to her bed.…

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

Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency within two hours for two (R10, R11) of four residents reviewed for abuse on the sample list of eight. Findings include: The facility's Initial Report to the state agency documents on 6/16/24, an allegation of sexual abuse was reported to V1, Administrator. This report documents the State Agency was notified on 6/17/24 at 12:42 PM by V, Administrator. On 6/21/24 at 1:15 PM, V1, Administrator, stated she received an allegation of abuse on 6/15/24 at 10:00 PM. V1 stated the report to the State Agency should have stated the date of occurrence as 6/15/24 not 6/16/24. V1 confirmed the report to the State Agency was not sent until 6/17/24, and the report was sent late.

Based on interview and record review, the facility failed to remove an alleged perpetrator from further resident contact when an allegation of abuse was received for two (R10, R11) of four residents reviewed for abuse on the sample list of eight. Findings include: On 6/21/24 at 9:56 AM, R10 stated R11 made sexually comments to her and exposed herself to R10 on three different occasions. R10 stated staff were notified. R10 stated the last night that R11 did this, it occurred twice in one night. R10's Incident Note written by V3, Licensed Practical Nurse, dated 6/16/2024 at 7:24 AM, documents R11 made sexually comments to R10, and exposed self to R10. This note documents R11 was put back to bed and the curtain was pulled between R10 and R11, but that R11 kept pulling the curtain back, and R11 was later found standing over R10 asking R10 to touch her. On 6/21/24 at 9:35 AM, V3 stated on 6/15/24 between 8:00 PM and 9:00 PM, it was reported to her R11 was making sexual comments to R10 and exposed self to R10. V3 stated she put R11 in bed and closed the curtain between them. V3 stated R11…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's right to privacy by discussing a private personal matter in front of floor staff. This failure affects one of three residents (R1) reviewed for privacy in the sample list of nine. Findings include: R1's Care Plan, dated 3/19/24, documents diagnoses including End Stage Renal Disease, Paraplegia, Morbid Obesity and Need for Assistance with Personal Care. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15/15. R1's Nurse's Note, dated 5/23/24 at 3:21 PM by V6, Registered Nurse, documents R1 stated R2 always has something in her mouth, and then R1 made the comment about her being good at something, and made a motion with his hand in front of his mouth. V6 documented R1 and R2 were in the hall and laundry staff member (V12) witnessed the comment. On 5/29/24 at 10:38 AM, R1 stated on 5/23/24, R1 had just gotten back from dialysis and was on his way back 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 interview and record review, the facility failed to report an allegation of abuse for two of three residents (R1 and R2) reviewed for abuse in the sample list of nine. Findings include: The facility's Abuse Prevention Program policy, dated October 2022, documents, Internal Reporting Requirements and Identification of Allegations Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. R1's Care Plan, dated 3/19/24, documents diagnoses including End Stage Renal Disease, Paraplegia, Morbid Obesity and Need for Assistance with Personal Care. R1's Minimum Data Set, dated [DATE] documents R1 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15/15. R2's Care Plan, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide oral care to a resident, provide supplies for the resident to do self-oral care, and ensure oral care supplies were within reach of the resident. These failures affects two (R1, R2) dependent residents of three residents reviewed for oral care in the sample list of three. Findings include: The facility's Mouth Care Policy, dated Revised April 2007, documents the purpose of this procedure is to keep resident's lips and oral tissue moist, to cleanse and freshen resident's mouths and to prevent infections of the mouth. 1. R1's undated Medical Diagnoses Sheet documents R1's diagnoses as: Acute Embolism and Thrombosis of Deep Veins of Left Upper Extremity, other Dysphagia, Altered Mental Status, Unspecified, Obstructive Sleep Apnea (Adult) (Pediatric), Acute Respiratory Failure with Hypoxia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side. R1's Physician Orders (POS), dated March 1- March 31,…

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

Based on interview and record review, the facility failed to obtain a physician ordered urine diagnostic test in a timely manner. This failure affected one of three residents (R4) reviewed for urinary tract infections in the sample of four. Findings Include: R4's Medical Diagnoses list, dated April 2023, documents R4 was diagnosed with Type II Diabetes, Urine Retention, Neuromuscular Dysfunction of the Bladder, and Malignant Neoplasm of Bladder. R4's Physician Communication and Progress Note, dated 3/1/23, documents R4 began to have Hematuria (blood in urine), R4's physician V18 was notified, and ordered a urine sample to be collected and sent to the lab for testing. R4's Lab Services Urine Microbiology Results, dated 3/5/23, documents R4's urine was collected and sent to the lab on 3/3/23. R4's urine's microbiology results detected Klebsiella Pneumoniae and Enterococcus Faecalis. On 3/20/24 at 11:32 AM, V3, Infection Control Nurse, confirmed R4 had Hematuria and a chronic urinary catheter. V3 confirmed V18 ordered a urinalysis to be completed on 3/1/23, and staff should have…

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 protect the right to be free from physical abuse by failing to prevent R2 from hitting R1 on the face. This failure had the potential to affect two (R1, R2) of three residents reviewed for abuse on the sample list of eight. Findings include: The facility's incident report, dated 1/3/24 at 5:20 PM, documents while at the dining room table, the aggressor (R2) walked over to R1 and slapped R1 twice on the cheek. On 2/3/23 at 8:50 AM, R1 stated R1 and R2 were in the dining room sitting at the same table, eating supper. R1 stated R2 got up from the table and was walking around and then someone told him to sit down. R1 stated R2 came back to the table and whapped R1 on the cheek. R1 stated R2 hit him with the back of his hand. R1 stated the reason R2 got mad and hit him was because they were telling R2 to sit down. At 10:34 AM, V18, Activity Aide, stated in regards to the incident occurring on 1/3/24 that R2 was walking towards the activity room and there was no one in there. V18 stated she was in the dining room passing out 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 redirection when wandering behaviors occurred for one (R3) of three residents reviewed for elopement on the sample list of eight. This failure resulted in R3 exiting the facility unattended and then falling onto the ground. Findings include: R3's careplan, dated 6/30/21, documents R3 is an elopement risk and wanderer. R3 is disoriented to place. R3 has impaired safety awareness. R3 wanders aimlessly. This care plan includes an intervention to redirect resident when wandering or exit seeking. R3's Incident Note, dated 12/13/2023 at 11:25 PM, documents at shift change (10 PM) resident (R3) was seen walking towards nurse's station, minutes later the alarm sounded. R3 was then found outside lying on the ground. On 2/2/23 at 3:56 PM, V23, Certified Nurse's Assistant, stated (on 12/13/23) V23 was at the nurse's station. V23 stated they were giving report and R3 walked past the nurse's station. V23 stated R3 walked down the hall and got past the double doors and turned right walking to the outside door. V23…

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 two residents (R1,R4) were free from physical abuse by another resident (R2) of three residents reviewed for abuse in a sample list of six residents. Findings Include: R2's Care Plan, revised 12/21/23, includes the following diagnoses: Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Dementia, Mood Disorder, Anxiety, Alcohol Induced Psychotic Disorder. R2's Care Plan includes the following problem: (R2) has a behavior problem cursing, Verbal and physical aggression, Refusal of care, crawling around on the floor, socially inappropriate and sexual comments, removing clothing. 1. R4's Minimum Data Set (MDS), dated [DATE], documents R4 is cognitively intact. R4's incidence report, dated 11/27/23, documents, Nurse notified the abuse coordinator that (R4) reported to her that (R2) was trying to take (R4's) walker and (R2) became physically aggressive and hit (R4) in his shoulder a couple of times. Nurse then did a head to toe…

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 Registered Nurse for 8 consecutive hours 7 days per week. This failure has the potential to affect all 95 residents residing in the facility. Findings include: The facility's nurse staffing schedules, dated 8/5/23 through 9/11/23, document on Wednesday 8/9/23, there was not a Registered Nurse (RN) on duty, on Thursday 8/10/23 there was one Registered Nurse on duty for 7 hours, on Saturday 8/12/23 and Sunday 8/13/23, there was one Registered Nurse on duty for 4 hours. On 9/7/23 at 11:47 AM, during medication administration observations, R15 was receiving an intravenous normal saline flush and an intravenous antibiotic (Cefepime) through a peripherally inserted central catheter (PICC line), requiring the services of a registered Nurse. The Facility Assessment, dated 6/15/23, documents the facility provides services including intravenous medications, and needs the resource of a Registered Nurse to provide competent support and care for the residents. On 9/8/23 at 12:03 PM, V2, Director…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary food service equipment, failed to maintain sanitary food storage areas, and failed to maintain sanitary food service areas (floors, walls, equipment surfaces). These failures have the potential to affect all 95 residents in the facility. Findings include: 1. On 9/5/2023 at 10:00AM, a chemical sanitizer dispenser was located to the left side of the kitchen three-basin sink. A residential-grade garden hose supplied water to the dispenser and was connected to a wall mounted spigot on the right side of the three-basin sink. Several residential Y (wye) adapters designed for residential outdoor use were installed between the spigot outlet and the water supply inlet of the dispenser. Neither the garden hose nor the Y adapters were labeled or marked by the manufacturer, as required, for indoor or food service use. On 9/6/2023 at 12:02PM, V9 (Dietary Manager) was present and reported being not sure if the garden hose and Y adapters supplying water to the three-basin chemical sanitizer dispenser were…

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

Based on observation, interview, and record review, the facility failed to obtain a determination of any required specialized mental health services for a resident by failing to conduct a Level 2 Pre-Admissoin Screen and Record Review (PASARR Level 2). This failure affects one resident (R2) out of two reviewed for Pre-admission Screening on the sample list of 36. Findings include: R2's Electronic Medical Record including diagnosis lists, Minimum Data Sets, census detail, and physician orders, document R2 admitted to this facility 11/2/22, with medical diagnoses including Paranoid Schizophrenia and Bipolar Disorder. On 9/5/23 at 9:59 AM, R2 was seated on the bed in R2's own room. R2 was wearing pants which were not pulled up completely, exposing R2's buttocks. R2 spoke with a matter-of-fact speech pattern, and did not exhibit any apparent bodily or social self-awareness. R2's Interagency Certification of Screening Results (Level 1 PASARR), dated 1/12/18, (from R2's former nursing facility) documents a reasonable basis to suspect Mental Illness or Developmental Disability. The portion…

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

Based on interview and record review, the facility failed to have a hospice plan of care for one (R301) of two residents reviewed for hospice on the sample list of 36. Findings include: R301's physician orders, dated 8/31/23, documents an order for hospice care. On 9/05/23 at 10:52 AM, R301's medical record did not contain a plan of care for hospice. R301's plan of care, dated 8/31/23, does not include a plan of care for hospice. On 9/6/23 at 1:52 PM, V6, Infection Preventionist, stated she was here when hospice came in and evaluated R301 for hospice. V6 stated there is a signed hospice agreement (contract) with physician orders in her office. V6 stated R301 does not have a hospice plan of care.

Based on observation, interview, and record review, the facility failed to ensure clothing in a closet was accessible for one (R8) of 24 residents reviewed for environment on the sample list of 36. Findings include: R8's Minimum Data Set assessment, dated 5/27/23, documents it is very important for R8 to take care of her personal belongings. On 9/5/23 at 2:40 PM, R8 stated she would like to be able to get to all her clothes but can't due to her roommates clothes and bed being in the way. At that time, a shelf with a rod that had clothes hanging from it was blocking R8's closet door. A bed was along the same wall as the closet. The foot of the bed and the shelf hanging on the wall blocked R8's path to the closet. On 9/7/23 at 8:25 AM, V13, Maintenance Director, walked into R8's room and confirmed the closet door and R8's clothing in the closet was not accessible to R8.