Effingham Healthcare & Senior Living

Based on interview and record review, the facility failed to ensure the services of a Registered Nurse for 8 consecutive hours per day, 7 days a week. This has the potential to affect all 32 residents living at this facility.The facility's Nursing schedule for August and September 2025 revealed the facility did not have 8 consecutive hours of RN (Registered Nurse) coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 or 8/9/25.On 9/9/2025 at 8:50am, V1 (Administrator) said the facility did not have the required 8 hours of continuous RN coverage for the dates of 9/7/25, 9/6/25, 8/24/25, 8/23/25 or 8/9/25.On 9/8/2025 at 11:00am, V2 (Director of Nursing) said she realizes the facility does not have 8 continuous hours of RN coverage during the weekends. V2 said the facility is actively advertising to hire more Registered Nurses to meet the requirement. V2 said V8 (RN) was the only RN providing RN coverage on 9/6/25 and 9/7/25, but V8 only worked 4 hours each day. V2 agreed the facility did not have the required 8 consecutive hours or RN coverage for the dates of 9/7/25, 9/6/25,…

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 interview and record review, the facility failed to provide 8 hours per day, 7 days per week Registered Nursing (RN) coverage for the facility. This failure has the potential to affect all 37 residents residing in the facility. The facility's June 2025 Nurse Schedule documents on 06/01/25, 06/14/25, 06/15/25, 06/28/25 and 06/29/25 the facility did not have a Registered Nurse (RN) scheduled. On 06/04/25, 06/06/25, 06/09/25, 06/12/25, 06/20/25, and 06/26/25, V2 (Director of Nursing/DON) was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on the dates of 06/04/25, 06/06/25, 06/09/25, 06/12/25, and 6/26/25, V2 worked 7.5 hours, and on 06/20/25, V2 worked 7 hours. The facility's July 2025 Nurse Schedule documents on 07/05/25, 07/06/25, 07/26/25 and 07/27/25, the facility did not have an RN scheduled for 8 hours. On 07/09/25, V2 was the RN scheduled for 8 hours. The Employee Timecard Report for V2 documented on 07/09/25, V2 worked 7.5 hours. The facility's August 2025 Nurse Schedule documents on 08/06/25 and 08/10/25, the facility did not have a RN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 (R1 and R6) of 3 residents reviewed for abuse in the sample of 9.1. R1's admission Record documented an initial admission date to the facility on [DATE] and included diagnoses of hemiplegia affecting left nondominant side, chronic obstructive pulmonary disease, asthma, type 2 diabetes mellitus, morbid obesity, osteoarthritis, obstructive sleep apnea, disorder of prostate, generalized anxiety disorder, major depressive disorder, calculus of ureter, and abdominal pain. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. A facility document titled Fax Worksheet Incident Report Form - Illinois Department of Public Health Notification documented on 08/01/2025, R1 reported that V4 (Licensed Practical Nurse/LPN) spoke inappropriately to him. V4 was sent home, and investigation immediately initiated.A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide substantial evening snacks to residents. This failure has the potential to affect all 37 residents residing at the facility. Findings include:Facility matrix dated 7/7/25 documents there are currently 37 residents living in the facility. On 07/10/25 at 9:30 AM the sign posted on the snack cart documents: breakfast 8:00 AM, lunch 12:00 PM, and dinner 5:00 PM.On 07/10/25 at 10:20 AM, R6 Who is alert and oriented, stated, the staff do not come and ask between after dinner and before bedtime if he would like a snack or a substantial snack such as a half a sandwich or a yogurt. On 07/10/25 at 11:40 AM, R8 who is alert and oriented, stated the staff do not come and ask if she would like a snack in the evening, after dinner. On 07/10/25 at 12:46 PM, R27 who is alert and oriented, stated, they (the staff) do not ask if he would like a snack after dinner in the evening time, but it would be nice if they did. On 07/10/25 at 12:49 PM, R22 who is alert and…

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

Based on interview, observation, and record review the facility failed to maintain floors, sinks and shower rooms in a clean, safe and sanitary condition for 20 of 20 (R2, R4, R6, R7, R8, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R26, and R27) residents reviewed for environment in a sample of 27. Findings include:On 07/09/25 at 8:12 AM, R2's floor by the bed contained a soiled brief and a soiled bed pad.On 07/09/25 at 9:15 AM, R2's floor by the bed contained a soiled brief and a soiled bed pad. On 07/09/25 at 9:30 AM, R2's floor by the bed contained a soiled brief and a soiled bed pad. On 07/09/25 at 9:45 AM the soiled/wet bed pad and soiled brief had been removed from R2's floor. On 07/09/25 at 12:45 PM, R6's floor was sticky, surveyor's shoes were sticking to the floor when walking over to the bed to speak with R6. On 07/09/25 at 1:40 PM, there was dried spilled liquid of the approximate size of 12 inches by approximately 6 inches on the floor of R4's room near the waste can. On 07/10/25 at 9:10 AM the south hall shower room contained a black substance along…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the doctor and obtain treatment orders when a change to a pressure area was detected and failed to apply heel protectors to prevent further skin breakdown for 3 of 4 residents (R3, R4, R5) reviewed for pressure areas in the sample of 27.Findings include:1. R4's admission record documents an admission date of 11/25/2015 with the following diagnoses in part; multiple sclerosis, chronic pain syndrome and autonomic neuropathy in diseases not elsewhere classified. R4's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 7, indicating R4 is severely cognitively impaired. Section M-Skin Conditions documents that R4 has pressure ulcers.R4's Order Summary Report documents R4 has treatment orders to her left ischial tuberosity, Right heel, right medial lower leg, right calf and behind her left knee.R4's Treatment orders on for her right heel document; Right medical heel: Apply barrier wipe q (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to timely drain a full indwelling catheter bag, increasing the resident's risk for infection for 1 of 3 (R2) residents reviewed for catheters in the sample of 27.Findings Include:R2's admission record documents an admission date of 6/12/17 with the following diagnoses listed in part; cerebral infarction, retention of urine, neuromuscular dysfunction of bladder and urinary tract infection, site unspecified.R2's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) was not completed due to resident is rarely/never understood.R2's Order Summary Report documents an active order to replace bedside drainage bag with leg bag each morning.R2's care plan documents resident has an indwelling catheter. resident will show no s/sx (signs and symptoms) of Urinary infection. with interventions including empty the drainage bag when needed.On 7/9/25 at 1:42pm, R2's leg catheter drainage bag was observed to be completely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Registered Nurse (RN) coverage 8 consecutive hours per day, 7 days per week. This failure has the potential to affect all 34 residents residing in the facility. Findings Include: The facility's May 2025 Nurse Schedule documents on 05/03, 05/04, 05/17, 05/18, 05/26, and 05/31/25 the facility did not have a Registered Nurse scheduled. On 05/07, 05/08, 05/09, 05/12, 05/15, 05/20, 05/21, and 05/23/25, V2 (Director of Nursing/DON) was the RN Scheduled for 8 hours. The Employee Timecard Report for V2 documented on 05/07, V2 worked 7.5 hours, on 05/08, V2 worked 7.5 hours, on 05/09, V2 worked 5.25 hours, on 05/12, V2 worked 7.25 hours, on 05/15, V2 worked 7.25 hours, on 05/20, V2 worked 7.5 hours, on 05/21, V2 worked 7 hours, and on 05/23, V2 worked 7.5 hours. The facility's June 2025 Nurse Schedule documents on 06/01, there was no RN scheduled. On 06/04 and 06/06, V2 (DON) was the RN scheduled for 8 hours. V2's Employee Timecard Report documented on 06/04, V2 worked 7.5 hours and on 06/06, V2 worked 7.5 hours. On…

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

Based on interview and record review, the facility failed to have a full time Registered Dietitian or full time Certified Dietary Manager on staff. This has the potential to affect all 34 residents residing in the facility. The Findings Include: On 9/17/24 on 9:00 AM, V4 (Cook) stated that they currently do not have anyone in the Dietary Manager role in the kitchen. V4 stated that there was someone, but they quit a couple days after she started. On 9/20/24 at 2:00 PM, V1 (Administrator) stated that she has not had anyone in the dietary manager role in the kitchen since June of 2024. V1 further stated that she is trying to find someone to fill that role but has not had any luck. V1 stated that they do have a Registered Dietitian come in once a month to review resident nutritional needs, but not full time. Review of the facility's Quality Assurance monthly meeting sign in sheets does not show a Dietary Manager attending the meetings since June (2024). On 9/20/24 at 2:00 PM, V1 stated that the Registered Dietitian provides the necessary information for the quality assurance meeting.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the kitchen was clean and sanitary to prevent cross contamination. This has the potential to affect all 34 residents residing in the facility. The Findings Include: During the initial tour of the kitchen on 9/17/24 at 9:20 AM, the following observations were made: -No paper towels were available at the hand wash sink -Stove top gas burners were dirty with burnt, dried up, and spilled food items on them -The sides of the oven were dirty with spilled food and grease down each side -The flat top grill on the stovetop grease/crumb trap was full of old food crumbs and grease -The floor around the oven had dried food matter under the oven -A non-handle scoop/Styrofoam cups were found in fortified powder, brown sugar and sugar bulk containers -A towel was stuck in the back door to keep it open On 9/17/24 at 12:15PM, a fan was observed sitting in the kitchen window with a screen blowing air into the kitchen from the outside. The fan had flies and dirt on the kitchen side of it, blowing onto drinks to be served…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 scheduled daily activities that met resident goals and preferences for six (R2, R3, R7, R12, R30 and R34) of six residents reviewed for activities in the sample of 24. Findings Include: 1. R2's admission Record documented an admission date of 3/1/24 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, and multiple sclerosis. R2's Minimum Data Set (MDS) assessment dated [DATE] under Interview for Activity Preferences documented that having books, newspapers, magazines, listening to music, being around animals, keeping up with the news, doing things with groups of people and doing favorite activities was somewhat important to R2, and going outside for fresh air when weather is good was very important to R2. 2. R3's admission Record documented an admission date of 7/21/2006 with diagnoses that included unspecified dementia, unspecified severity, with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare food in the proper form of the diet order for 5 of 5 (R1, R16, R18, R19 and R30) residents reviewed for menus meeting resident needs in the sample of 24. The Findings Include: 1. R1's current order summary report lists diet order as: regular diet, pureed texture. 2. R16's current order summary report lists diet order as: regular diet, pureed texture. 3. R18's current order summary report lists diet order as: regular diet, mechanical soft texture. 4. R19's current order summary report lists diet order as: regular diet, mechanical soft texture. 5. R30's current order summary report lists diet order as: regular diet, mechanical soft texture. On 9/17/24 at 12:00 PM, during lunch meal observation, V4 (Cook) was preparing the altered diets for residents on mechanical soft and puree. V4 stated that she did not have to prepare the meal any different for the mechanical soft diets because it was meat loaf. V4 then pureed the meat loaf, spinach and Au Gratin potatoes and did not use any liquid in the food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and record review, the facility failed to follow Infection Control practices for 9 of 12 residents (R1, R2, R4, R6, R8, R9, R11, R12, and R17) reviewed for infection control in the sample of 24. The Findings Include: 1. On the initial tour of the facility on 09/17/2024 beginning at 9:30 AM, there were no resident rooms observed in the facility with signage on the doors indicating residents were on enhanced barrier precautions. On 09/17/2024 a Matrix for Providers (form CMS 802) was provided by the facility with no residents marked for transmission-based precautions. On 09/18/2024 at 08:30 AM, during screening of residents, there were no resident rooms observed in the facility with signage on the doors indicating residents were on isolation or enhanced barrier precautions. On 09/18/2024 at 11:01 AM, V2 (Director of Nursing/DON) stated that there is no one currently on isolation. V2 stated that Enhanced Barrier Precautions are for residents with wounds and catheters. V2 stated the facility has no open wounds, so no one is on Enhanced Barrier…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident representatives in writing of hospital transfers for 1 (R3) of 1 resident reviewed for hospitalizations in a sample of 24. Findings Include: R3's admission Record documented an original admission date to the facility of 7/21/06. R3 was alert to person only. R3's Responsible Party was documented as being V22 (Guardian). R3's Progress Notes documented on 8/23/24, R3 was transported and admitted to the local hospital with a reddish/brown emesis throughout the day, along with unable to keep medication down. On 09/19/24 at 12:04 PM, V1 (Administrator) stated that the resident and/or their representative were notified of the hospital transfer and/or admission via phone. V1 confirmed that documentation is not provided to the resident representative in writing. V1 stated R3 is not cognitively intact as their baseline status.

Based on interview and record review, the facility failed to notify resident representatives in writing of the bed hold policy during resident transfers for 1 (R3) of 1 resident reviewed for notice of bed hold policy upon transfer in the sample of 24. Findings Include: R3's admission Record documented an original admission date to the facility of 7/21/06. R3 was alert to person only. R3's Responsible Party was documented as being V22 (Guardian). R3's Progress Notes documented on 8/23/24, R3 was transported and admitted to the local hospital with a reddish/brown emesis throughout the day along with unable to keep medication down. On 09/19/24 at 12:04 PM, V1 (Administrator) stated that the resident representative was notified of the bed hold policy via phone and sent with the resident. V1 confirmed documentation was not provided to the resident representative in writing. V1 stated R3 is not cognitively intact as their baseline status. The facility did not provide evidence of a policy and procedure for bed holds upon request.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 3 (R8, R9, and R21) of 12 residents reviewed for accuracy of assessments in the sample of 24. Findings Include: 1. R9's admission Record documented an initial admission date of 08/02/2024. Diagnoses listed on this document include chronic obstructive pulmonary disease, cerebrovascular disease, spastic hemiplegia, chronic kidney disease, sleep apnea, unspecified dementia, gastro-esophageal reflux disease, bipolar disease, anxiety, and retention of urine. R9's Notice of PASRR Level II Outcome dated 07/22/2022 documented that You have a Level II PASRR Condition of Bipolar Disorder Level II Outcome: Level II - Approved No SS. R9's MDS with an Assessment Reference Date of 10/12/2013 documented this MDS as being an annual assessment. Section A1500 Preadmission Screening and Resident Review (PASRR) asks Is the resident currently considered by the state level II PASRR process to…

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

Based on observation, interview and record review the facility failed to provide services of a Registered Nurse for eight consecutive hours per day, seven days a week. This has the potential to affect all 38 residents residing at the facility. Findings include: On 3/26/2024 at 9:30am, V1 (Administrator) was asked to provide documentation of the facility having the services of a Registered Nurse, 8 consecutive hours a day, for seven days a week. At around 1:00pm, V1 provided the facility's nurse schedules for the months of January 2024, February 2024 and March 2024. The facility's March 2024, February 2024 and January 2024 Nurses Schedules document only V5, V6, V12 -V20 LPN's (Licensed Practical Nurses) were scheduled to provide patient care during the months provided. There were no RN's (Registered Nurses) documented as working during those three months. On 3/26/2024 at 2:00pm, V6 (LPN) reviewed the March 2024, February 2024 and January 2024 Nurses Schedules and verified all nurses on the schedule (V5, V6, V12-V20) were all LPN's and none of the nurses on the schedule, who had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from mental abuse/mistreatment for 1 (R2) of 3 residents reviewed for abuse in the sample of 19. Findings Include: R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. The interventions documented for this Focus Area include, Allow extra time for resident to respond, allow resident to complete thought process before responding. Do not finish sentences for resident . Avoid complex lengthy communication. Segment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement the facility abuse policy when they neglected to identify an allegation of abuse, and timely and thoroughly investigate an allegation of abuse for 1 (R2) of 3 residents reviewed for abuse in the sample of 19. Findings Include: The undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN-Licensed Practical Nurse). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present Staff interviews: (V13/CNA-Certified Nursing Assistant) reported to this writer after the allegation when all staff members were being interviewed that she was informed by (V14), LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 report an allegation of abuse to the State Survey Agency for 1 of 1 (R2) resident reviewed for abuse in the sample of 19. Findings Include: The undated Final (Investigation) Report documents, .Summary: On the date of 1/3/2023, (State Survey Agency) surveyor was present in the building and reported to this writer verbal abuse allegedly occurring involving resident (R2) and Nurse, (V9/LPN-Licensed Practical Nurse). Throughout the investigation it was discovered that the alleged event occurred on 12/23/2023. This writer had not been notified of any allegations until 1/3/2023. (V9) was immediately placed on suspension pending investigation and ensuring of (R2's) safety was present .Conclusion: In conclusion, the accusation of abuse to (R2) cannot be substantiated. (V9) was suspended pending the outcome of the investigation and was made aware of this on 1/3/2023. Due to the allegation being unfounded, she has been released from suspension and return…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and thoroughly investigate an allegation of abuse for 1 of 3 (R2) residents reviewed for abuse in the sample of 19. Findings Include: R2's admission Record with a print date of 1/4/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include early-onset cerebral ataxia, paraplegia, bipolar disorder, major depressive disorder, heart disease, muscle weakness, and anxiety. R2's MDS (Minimum Data Set) dated 10/3/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact. R2's current Care Plan documents a Focus Area of The resident (R2) has a communication problem r/t (related to) Expressive Aphasia with an initiation date of 11/20/23. The interventions documented for this Focus Area include, Allow extra time for resident to respond, allow resident to complete thought process before responding. Do not finish sentences for resident . Avoid complex lengthy communication. Segment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident an advanced written notice of involuntary discharge with appeal rights for 1 (R1) of 3 residents reviewed for discharge in the sample of 19. Findings Include: R1's admission Record with a print date of 1/4/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include quadriplegia, adjustment disorder with anxiety, adjustment disorder with mixed disturbance of emotions and conduct, spastic hemiplegia, neurogenic bowel, and pressure ulcers. R1's BIMS (Brief Interview for Mental Status) dated 11/03/23 documents a score of 15, which indicates R1 is cognitively intact. R1's MDS (Minimum Data Set) dated 12/12/23 documents under Section G, R1 is dependent on staff for all Activities of Daily Living (ADL's). Under Section I, this same MDS documents a diagnosis of quadriplegia. R1's undated Care Plan documents a Focus area with an initiation date of 11/04/23, Dependent for ADLs- Unable to assist/Assists only minimally.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 services of a Registered Nurse for eight consecutive hours a day seven days a week. This has the potential to affect all 43 residents residing at the facility. Findings Include. The facility document dated November 2023 titled, Nurses Schedule documents V2, as the only registered nurse working 11/20, 11/21, and 11/22 with an X in the box for her name. The key under the schedule documents: x = 6a-6p or 6p - 6a. On 11/20/23 at 11:00 AM, V2 (Director of Nursing) was observed arriving at the facility. On 11/21/23 at 9:15 AM, V2 was observed arriving at the facility. At 9:20 AM, V2 was observed leaving the facility and returned at approximately 9:50 AM. On 11/21/23 at 1:50 PM, V2 stated, she had to leave today at approximately 2:00 PM. On 11/21/23 between 2:15 PM and 3:45 PM there was no RN observed at the facility. On 11/21/23 at 2:15 PM, V12 (Minimum Data Set Coordinator) stated, V2 had left, she stated, she did not know if or when V2 was returning. On 11/22/23 at 9:45 AM, V2 was not at the facility. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to serve meals at the facility's designated scheduled times. This has the potential to affect all 43 residents residing at the facility. Findings include: The facility document dated 06/06 titled, Meal Times states: The facility will serve at least three meals per day with no more that fourteen (14) hours between the serving of supper and breakfast. Procedure: 1. Meal service begins at: Breakfast - 8:00 AM (with the 8:00 handwritten in), Lunch - 12:00 PM (with the 12:00 handwritten in) and Supper - 5:00 PM (with the 5:00 PM handwritten in). On 11/20/23 at 1:30 PM, V1 (Administrator) stated, last week on Tuesday lunch did come out after 1:00 PM, she knows there was some unhappy people. On 11/21/23 at 1:50 PM, V5 (Dietary Manager) stated, she has worked here since August. Breakfast is at 8:00 AM, lunch is at 12:00 PM, and dinner is at 5:00 PM. V5 stated, the halls trays go out first then the dining room trays. V5 stated, some of her staff is new…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 diets as ordered and failed to follow pre-planned menus and standardized recipes. This failure has the potential to affect all 37 residents who reside in the facility. Findings Include: 1. On 8/16/23 at 12:53 PM, R12 was observed being served a puree diet of tuna noodle casserole, mixed vegetables, apple sauce, and a (name brand) supplement cup. Review of R12's meal card documented R12 should receive double protein portions, which was not observed being served. On 8/16/22 at 12:55 PM, V4 (Cook) confirmed R12 was not served a double protein portion by mistake. At 1:00 PM, V4 was observed providing R12 an additional serving of tuna noodle casserole. On 08/17/23 at 09:33 AM, V1 stated that it her expectation that prescribed diets are followed as ordered. On 08/18/23 at 12:26 PM, R12 was observed receiving her meal tray. No (name brand) supplement cup was noted on the tray. V1 (Administrator) was notified of the lack of a supplement cup served, which she acknowledged, and retrieved one for R12. Review of…

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

Based on observation, interview and record review the facility failed to offer meal substitutes and honor resident preferences. This has the potential to affect all 37 residents residing in the facility. The Findings Include: 1. On 8/15/23 at 10:30 AM, R17 stated that he does not get options of alternate foods offered at mealtime. R17 stated that he does not know what is being served until he gets it delivered and most of the time the food is delivered late. R17 was alert to person, place and time. 2. On 8/16/23 at 1:00 PM, V11 (Family Member) stated that her husband R37 has been in the facility since January 2023 and hasn't been asked food preferences. During lunch mealtime on this day V11 stated that they sent R37 applesauce, and he does not like that. The menu for the lunch meal had German chocolate cake as the planned dessert. R37's meal card did not have preferences or supplements listed on it. V11 does not recall being asked R37's food preferences upon admit. On 8/16/23 all residents received applesauce as the dessert item due to the German chocolate cake not being completed…

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

Based on observation, interview, and record review the facility failed to execute dietary services for timely meal distribution. The failure has the potential to affect all 37 residents residing in the facility. Findings Include: Mealtimes as provided by the facility documents lunch is at 12:00 PM. On 08/15/23 at 12:33 PM, the first meal tray was observed being served in the dining room. On 8/17/23 at 12:20 PM, R10 was observed placing her head on the dining room table while waiting for her meal and falling asleep. On 8/17/23 at 12:32 PM, the first meal tray was observed being served in the dining room. On 08/18/23 at 11:42 AM, staff were observed wheeling residents into the dining room, sitting them at tables for lunch. On 08/18/23 at 12:14 PM, resident hall trays were observed leaving the kitchen for delivery. On 08/18/23 at 12:15 PM, the first meal tray was observed being served in the dining room. On 8/17/23 at 12:40 PM, R2 stated that meals generally run late, but it has been worse lately. R2 stated mealtimes had recently been moved from 11:30 AM to 12:00 PM, but it makes no…

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

Based on observation, interview and record review the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner. This has the potential to affect all 37 residents residing in the facility. The Findings Include: During the initial walk through of the kitchen on August 15th at 9:00 AM the following items were found: Raw beef was thawing on the rack above fresh produce in the refrigerator. V5 (Dietary Supervisor) was observed to have facial hair without being properly restrained. The countertop mixer was observed to have dried old food splatter in and around the mixer. The refrigerator unit next to the countertop where food is prepared was splattered with old, dried food. The oven top and side of oven was covered in old dried splattered food. The gas pipe leading to the stove had a thick layer of dust and grease accumulated on it and is located directly over the cooks preparation table. The open shelves under the countertop where cooks prepare food was found to have old, dried food particles and dried spilled liquids on the shelving. 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 serve foods at the desired palatable temperature for 33 (R2, R3, R4, R5, R7, R8, R9, R10, R11, R13, R14, R15, R16, R17, R18, R20, R21, R22, R23, R24, R25, R26, R27, R29, R31, R32, R33, R34, R35, R36, R38, R39, R40) of 33 residents reviewed for palatability in the sample of 42. Findings Include: On 08/15/23 at 10:30 AM, R17 stated that he eats his meals in his room and the food is normally cold. R17 is alert to person, place and time at this encounter. On 08/15/23 at 12:33 PM, R11 was observed being served Salisbury Steak, which she reported was, barely warm at best. R11 was observed as being alert and oriented to person, place, and time during this encounter. On 08/16/23 at 1:00 PM, V11 (Family Member) stated that she is here for every lunch meal. V11 states that the trays take a while to get down there to her husband's room, and more often than not the food is barely warm. On 08/18/23 at 12:35 PM, a test tray was requested with temperatures of the foods being taken by V4 (Cook) with V1 (Administrator)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 12 (R37) residents reviewed for assessments in a sample of 42. The Findings Include: A quarterly MDS assessment dated [DATE] documents in Section K0300 that R37 has not had weight loss of 5% or more in one month or 10% in six months and Section K0510 documents no indicating that R37 is not on a mechanically altered diet. R37's Physician's Order Sheet (POS) dated May 1st, 2023, to May 31st, 2023, documents a diet order of Regular, Pureed, thin liquids. R37's monthly weight grid documents a February weight of 153.6 pounds, March weight of 149.2 pounds, April weight of 138.8 pounds, and a May weight of 137 pounds. On August 22, 2023, at 1:00 PM, V12 (MDS Coordinator) stated that those were coded in error on the May MDS and will be corrected on this upcoming MDS that is due in August.

Based on interview and record review the facility failed to develop a person-centered comprehensive care plan for 1 of 12 (R37) residents reviewed for weight loss in a sample of 42. The Findings include: R37's face sheet documents an admit date of 1/25/23 and includes the following diagnosis: dementia, Alzheimer's, dysphagia, and feeding difficulties. R37's current physician order sheet documents a diet order of a regular diet/pureed texture, regular/thin consistency, supercereal at breakfast. and magic cup supplement at lunch and 90 milliliters of 2.0 calorie supplement twice daily. R37's order for the supercereal and magic cup original order date is 4/29/23 and 90 milliliters of 2.0 supplement once daily start date of 6/6/23 and was increased to two times a day on 8/17/23. A dietary note made on 8/4/23 recommended to increase the 2.0 calorie supplement to twice daily from once a day due to the resident having weight loss trends over 6 months. On 8/22/23 at 11:45 AM, V1 (Administrator) confirmed that R37's weight loss and dietary supplementation were not documented anywhere in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide dining assistance to residents as needed for 2 of 11 residents (R26, R34) reviewed for dining in the sample of 42. Findings Include: On 08/16/23 at 12:41 PM, R34 and R26 were observed sitting at the same table in the dining room. No staff were observed as being present at the table. R34 and R26 had been served a regular diet of tuna noodle casserole, mixed vegetables, roll, and cup of applesauce as their meal. R34 was observed attempting to drink her applesauce out of the cup, with no success. R34 was then observed using her fork to scoop tuna noodle casserole off of her plate and into her full applesauce cup. On 8/16/23 at 12:45 PM, R34 was again attempting to drink her applesauce cup with tuna noodle casserole on top of it, with no success. No staff were present at table, intervening or assisting R34. On 8/16/23 at 12:46 PM, R26 began eating mixed vegetable off of her plate with her fingers. Silverware was observed being present,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a residents medications were available for administration for one of seven residents (R7) reviewed for medication administration in the sample of forty-two. Findings include: R7's Face Sheet documented an admission date of 7/28/23, and diagnoses including Chronic Obstructive Pulmonary Disorder, Insomnia, and Bipolar Disorder, Unspecified. On 8/17/23 at 10:05am, R7 was alert and oriented to person, place, and time. R7 stated she was in special education services throughout school, and that she cannot read or write. R7 stated, Earlier this month, (August 2023), I went a few days without some of my psych(iatric) med(ications), they said they didn't have them here, I'm not sure what the problem was. I was having problems before that though, with not sleeping and feeling like I am going crazy sometimes, maybe because when I went to the ER (Emergency Room) on 7/31/23, they took me off some of my psych meds because I had low sodium. I went back to ER…

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