Allure Of Galesburg

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY B. Findings include: Facility Fall Prevention Program, dated 2024, documents: each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls; the nurse will indicate on the Resident's fall risk and initiate interventions on the Resident's base line care plan, accordance with the Resident's level of risk; each Resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care; and interventions will be monitored for effectiveness and the plan of care revised as needed. 1. R24's Fall Report (#410), dated 12/22/24, document a fall in R24's bathroom hitting head on tub. The Report or R24's Care Plan does not document fall interventions. R24's Fall Report (#411), dated 12/26/24, documents a fall in R24's bathroom (communal bathroom). R24 was ambulating without assistance and got up from the toilet, went to sit in wheelchair, feet slipped on wet floor and…

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

Based on observation, interview, and record review the facility failed to ensure safe handling of oxygen humidification vessels and change oxygen supplies (oxygen tubing and humidification bottles) for four of four residents (R15, R23, R24 and R37) reviewed for oxygen therapy in a sample of 42. Findings include: The facility's undated Oxygen Administration policy documents the following: Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty, every 72 hours or per facility policy. 1. R23's correct physicians Order sheet documents Oxygen at 2L (liters) per minute per nasal cannula via O2 (Oxygen) concentrator and/or tank PRN (as needed) to maintain pulse ox (oximetry above 90%. On 6/29/25 at 9:12am R23 was seated in her room with humidified oxygen in place via nasal cannula at 2 liters per minute connected to the oxygen concentrator at her bedside. R23's oxygen humidification bottle was dated 6/9/25 and the oxygen tubing was not dated. 2. R15's medical record documents R15 has a diagnosis of COPD/Chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Influenza and Pneumococcal immunizations were offered to four of five residents (R26, R87, R81, R498) reviewed for immunization compliance in a sample of 42. Findings include: The Influenza Vaccination, no date, documents the influenza vaccination will be routinely offered annually from October 1st through March 31st. The Pneumococcal Vaccine (Series), no date, documents each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. R26 was admitted on [DATE]. The Immunization Audit Report sheet did not include a pneumococcal immunization history or evidence the vaccine was offered, declined, or administered. R81 was admitted on [DATE]. The Immunization Audit Report sheet did not include a pneumococcal immunization history or evidence the vaccine was offered, declined, or administered. R87 was admitted on [DATE]. The Immunization Audit Report sheet did not include an influenza or 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 assess two residents (R12 and R87) for available walking pass privileges of 24 residents reviewed for choices in a total sample of 42. Findings include: The facility's undated Walking Pass Program documents that the program is designed to help you function in healthy ways both inside the facility and out in the community. Your involvement in the Walking Pass Program is a privilege that requires you to meet all referral criteria before you first utilize your walking pass. Your participation in the program will help you develop necessary skills for activities of daily living and successful community life while increasing your independence. The walking pass program requires you to meet. criteria of each level before advancing to the next level. 1. R12's Medical Record documents he was admitted on [DATE] with diagnoses to include but not limited to depression, schizoaffective disorder, narcissist, and antisocial personality. On 6/29/25 at 8:00 AM, R12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident (R26) was free from verbal abuse of two residents reviewed for abuse in a total sample of 42. Findings Include: The Abuse, Neglect, and Exploitation policy dated 2/3/25 documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The Facility's Long-Term Care Facility & IID (Individuals with Intellectual Disabilities) Serious Injury Incident Communicable Disease Report dated 5/2/25 documents that V11 (Registered Nurse) and V12 (Certified Nurse Aide) both reported that they overheard V10 (Certified Nurse Aide) tell R26 to Shut 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 2. R13's Physicians Orders include the following orders: Cleanse wound to sacrum with normal saline, pat dry and apply hydrocolloid (TTHSA) every day shift, every Tuesday, Thursday and Saturday for pressure wound. R13's physicians Orders also the following wound care: Cleanse open area to right hip with normal saline, pat dry and apply a border form (bordered dressing) until healed one time a day for opening to old incision. R13's current TAR/Treatment Administration Record includes the task to implement EBP/Enhanced Barrier Precautions every shift. On 7/1/25 at 11:00am there were no gowns in or outside of R13's room for facility staff to utilize and no signage indicating Enhanced Barrier Precautions were in place. On 7/1/25 at 11:30am V13 LPN/Licensed Practical Nurse, V21 and V22 CNAs/Certified Nurse's Assistant entered R13's room to perform R13's wound cares. V13 performed wound cares for R13's stage 3 sacral pressure ulcer and right ischial (hip) opened incisional wound area. V21 and V22 CNAs assisted in…

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

Based on observation, interview and record review the facility failed to prevent resident to resident physical abuse for one resident (R4) of four residents reviewed for abuse in the sample of four. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2/3/25 documents: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or anguish, which can include staff to resident abuse and certain resident to resident altercations. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled by the use of technology. Physical abuse includes but is not limited to hitting, slapping, punching, biting, and kicking. On 4/4/25 at 2:01pm Progress Narrative Note indicates R4 was getting coffee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 93 residents residing within the facility. Findings include: The facility's Resident Roster dated 1-31-25 documents the resident in-house census as 93 residents. The facility's Staff Training and Staff In-Service Logs dated 1-1-24 through 2-3-25 do not include documentation of facility staff receiving annual QAPI training. On 2-4-25 at 10:30 AM V17 (Corporate Nurse) stated, No staff at this facility have received annual QAPI training. Our training program did not list this as one of the trainings that needs completed yearly.

Based on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of staff-to-resident sexual abuse to the State Agency for one of three residents (R1) reviewed for Abuse in the sample of four. Findings include: The facility's Abuse, Neglect, and Exploitation policy dated 2024 documents, Reporting/Response: 1. The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within the specified timeframes: a. Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. The facility's Serious Injury Incident and Communicable Disease Report dated 1-29-25 documents (R1) reported that (V3/CNA/Certified Nursing Assistant) has been having inappropriate sexual encounters with (R1). (V3) previously resigned from her position. Last day to work was 1-7-25. (Local) police department notified. (Primary Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview the facility failed to ensure two of five residents (R1 and R5) were free from physical abuse. Findings Include: The Facility's undated Abuse, Neglect and Exploitation policy documents it is the policy of facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation resident property. The policy documents Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or or physical condition, cause physical harm, pain or mental anguish It includes verbal abuse, sexual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview the facility failed to maintain accurate clinical records for four (R1,R2,R3 and R4) of five residents reviewed for medical record accuracy. Findings Include: The Facility's undated Documentation in Medical Record policy documents Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident;s progress through complete, accurate and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation or care service occurred. An abuse investigation dated 10/18/24 documents that R1 and R2 were witnessed by staff to be having a verbal disagreement in the main dining room. R1 was over heard telling R2 loudly to get away from him. R1 was seen pushing a chair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen waste/trash was secured by leaving the lids left open on the trash receptacle located outside. This failure has the potential to affect all 90 residents residing in the facility. FINDINGS INCLUDE: The Centers for Medicare & Medicaid Service/CMS Form 671, entitled Long Term Care Facility Application for Medicare and Medicaid, dated 7/9/2024, document 90 residents reside in the facility. The facility policy, entitled Disposal of Garbage and Refuse, not dated, document: Policy: The facility shall properly dispose of kitchen garbage and refuse. 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. On 7/9/2024, at 9:00 a.m., during the initial kitchen tour, with V7/Head Cook, the outside trash dumpster/receptacle lids were observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food service areas and equipment was free of pests/insects, in that gnats were observed on and flying around the juice dispenser spigot/handle located in the facility kitchen. This failure has the potential to affect all 90 residents residing in the facility. FINDINGS INCLUDE: The Centers for Medicare & Medicaid Service/CMS Form 671, entitled Long Term Care Facility Application for Medicare and Medicaid, dated 7/9/2024, document 90 residents reside in the facility. The facility policy, entitled Sanitation Inspection, not dated, document: Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. On 07/9/2024, at 8:50 a.m., during the initial kitchen tour, with V7/Head Cook, the juice dispenser spigot/handle was observed to have gnats flying around and on the dispensing end. On 7/9/2024, at 8:50 a.m., V7 confirmed the gnats were present and they shouldn't be present as 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 and interview, the facility failed to ensure the women's shower room was clean, functional and protected the resident's privacy. This failure potentially affects all sixteen females residing on the E Wing (R3, R5, R9, R11, R16, R22, R27, R33, R54, R50, R55, R58, R70, R78, R90, R394) that utilize the women's shower room. Findings include: 1. On 7/9/24 at 9:45 AM, R16 stated The shower heads are broken (in the women's shower room). There is hardly a stream of water that comes out (of the shower head). 2. On 7/9/24 at 10:00 AM, R394 stated The showers don't work and there is no water. Even the toilets don't flush. 3. On 7/9/24 at 10:15 AM, R27 stated They need to clean up the shower room. 4. On 7/9/24 at 10:20 AM, R54 stated The bathrooms have mold, there is no soap, showers suck, bathroom sinks don't work and they keep saying they are going to fix it but they don't. The bathroom had poop in the toilet and I had to flush the toilet like five times to get it down. 5. On 7/9/24 at 2:00 PM, R58 stated The bathrooms have been like that since I got here probably three…

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

Based on observation and interview, the facility failed to ensure the women's shower room was free from hazards. This failure potentially affects all sixteen female residents on the E-Wing (R3, R5, R9, R11, R16, R22, R27, R33, R54, R50, R55, R58, R70, R78, R90, R394) that utilize the women's shower room. Findings include: 1. 07/09/24 01:55 PM, a 2-blade disposable razor was observed on the counter in the women's shower room which is utilized by the E Wing residents. 2. On 7/9/24 at 1:45 PM, V13 (Licensed Practical Nurse) stated That (disposable razor) should absolutely not be in here. The only way they (residents) even have access to them (disposable razors) are if staff give them (razors) to them (residents). They (razors) are kept locked up.

Based on record review and interview, the facility failed to develop a skin care Plan of Care for one resident (R30); and failed to develop a foot wound Care Plan for one resident (R13), of 18 residents reviewed for Care Plans in a sample of 53. Findings includes: The facility's Comprehensive Care Plans Policy, Undated, documents: It is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS/Minimum Data Set assessments. 1. On 7/9/24 at 9:45 am, R30's bilateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record reviews, and interview, the facility failed to ensure skin care concerns were addressed, failed to provide skin treatments, and failed to notify physician about skin concern for one resident (R30) of 18 residents reviewed for quality of care in a sample of 53. Findings Include: Facility's Skin Assessment Policy, Undated, documents: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission, daily for three days, and weekly thereafter. Consider the general status of the resident's skin. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. Facility's Resident Rights Policy, Undated, documents: The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The (State) Ombudsman Program Resident Rights for…

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

Based on observation, interview and record review the facility failed to provide physician orders for the administration of oxygen and failed to change oxygen tubing/humidifier bottles per facility policy for one resident (R13) of three residents reviewed for oxygen therapy in the sample of 53. Findings include: Facility Policy/Oxygen Concentrator dated 2023 documents: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Oxygen is administered under the orders of the attending physician, except in case of an emergency. The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc). Facility Policy/Oxygen Administration dated 2024 documents: Oxygen is administered under orders of a physician, except in cases of an emergency. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. On 7/9/24, 7/10/24 and 7/11/24 R13 was in bed with an oxygen cannula administering oxygen at 3.5L (liters) during multiple observations on all three…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 identify an appropriate indication for use and identify target behaviors for the use of an antipsychotic medication for one resident (R13) of five residents reviewed for unnecessary medications in the sample of 53. Findings include: Facility Policy/Use of Psychotropic Medication dated 2024: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Enduring Conditions (non-acute, chronic, prolonged): The resident's symptoms and therapeutic goals shall be clearly and specifically identified and documented. Current Physician Orders indicate order for Seroquel (antipsychotic) 25mg (milligrams) at bedtime related to anxiety disorder and Major Depressive Disorder (date initiated 3/19/24). Physician…

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

Based on interview and record review the facility failed to ensure two residents (R1 and R3) was free from verbal abuse by an employee of three resident reviewed for abuse. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2023 documents: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. Final Incident Investigation Report dated 5/16/24 indicates On 5/10/24 V5, RN (Registered Nurse) was overheard being verbally inappropriate with R3. Report indicates V5 was immediately separated from all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise care plans for three residents (R1, R3, R4) who smoke of three residents reviewed for care plan revision. Findings include: Facility Policy/Comprehensive Care Plans dated 2023 documents: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. On 5/14/24 at 2:30pm V2, DON (Director of Nursing) stated R1, R3 and R4 have all had their smoking privileges taken away due to repeatedly breaking the smoking rules. On 5/16/24 at 3:00pm V2, DON stated that R1's smoking privileges have been revoked since 12/5/23. NP (Nurse Practitioner) note dated 5/7/24 indicates R1 has lost all smoking privileges due to 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 prevent staff verbal abuse for one (R1) and failed to prevent resident-to-resident physical abuse for two of two (R5 and R6) residents reviewed for abuse in the sample of three. Findings include: The facility's undated Abuse, Neglect and Exploitation policy and procedure documents: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview the facility failed to prevent abuse for two of five residents (R1 and R5) reviewed for abuse in the sample of five . Findings include: The Facility's undated policy Abuse, Neglect and Exploitation documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Facility's Abuse policy documents the definition of abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The Facility's Abuse policy documents the definition of verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent mistreatment and verbal abuse of one resident (R2) of four residents reviewed for abuse. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2022 documents: Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse means the oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment means inappropriate treatment or exploitation of a resident. Alleged Violation: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance 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 interview and record review the facility failed to immediately report an allegation of verbal abuse to the Abuse Coordinator for one resident (R2) of four residents reviewed for abuse. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2022 documents: Alleged Violation: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Reporting of all alleged violations to the Administrator, the state agency, adult protective services and to all other required agencies within specific timeframe's: Immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Final Incident Investigation Report dated 10/13/23 indicates that on 10/7/23 at 9:12pm V9, CNA (Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prevent resident to resident physical abuse for two of three residents (R1, R2) reviewed for abuse in the sample of three. Findings include: The facility's Abuse, Neglect and Exploitation policy dated 2022, states It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. R1 is a [AGE] year-old resident that was admitted to the facility on [DATE] and has diagnoses which include, Paranoid Schizophrenia, Psychotic Disorder with Delusions, and COVID-19 (8/16/23). R1's Minimum Data Set 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.

Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for eight hours in a 24-hour period. This failure has the potential to affect all 94 residents residing in the facility. Findings Include: The facility's nursing schedule dated 3/9/23 through 4/5/23 does not have an RN scheduled for eight hours a day on 3/22/23 and 3/25/23. 4/12/23 1:04 PM, V2, Director of Nursing (DON), verified there was no RN coverage for 3/22 and 3/25 and stated, That would be correct, we had an issue of not having enough RN's to cover all the days. Facility census report provided by V3, Minimum Data Set (MDS) Coordinator, dated 4/11/23 documents 94 residents currently residing in the facility.

Based on interview and record review, the facility failed to complete annual performance reviews and education based on the performance review of the Certified Nursing Assistants (CNA) working in the facility. This failure has the potential to affect all 94 residents residing in the facility. Findings include: V4's, CNA, personnel file documents V4's start date of 4/18/21 and does not include a performance review at least every 12 months or the in-service education provided to the CNA based on his/her performance review. V9's, CNA, personnel file documents V9's start date of 12/3/19 and does not include a performance review at least every 12 months or the in-service education provided to the CNA based on his/her performance review. On 4/13/23 at 10:23 AM, V5, Regional Nurse Consultant, verified V4 and V9's, CNA, annual performance reviews and in-services based on the performance were not completed and stated I'll be honest with you, our communities haven't been the best at completing the CNAs annual competency evaluations. We don't have any completed on any of the CNAs. here.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 double lock refrigerated liquid controlled medications, failed to document and reconcile controlled medications after administration and failed to ensure shift to shift controlled medication reconciliation was completed. This failure has the potential to affect all 48 residents in the facility who receive controlled medications. Findings include: Facility Policy/Controlled Substance Administration and Accountability dated 2022 documents: The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. The Controlled Drug record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. Areas without automated dispensing systems…

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

Based on observation, interview and record review the facility failed to provide an ongoing Activity Program for 3 residents (R68, R74, R12), this failure has the potential to affect all 94 residents who currently reside in the facility. Findings Include: The Facility's undated Activity Policy documents It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Activity Staff Schedule for March 2023 documents no staff members on the schedule at all for activities on 3/10/23, 3/11/23, 3/12/23, 3/15/23, 3/18/23, 3/20/23, 3/24/23, 3/25/23, 3/26/23 and 3/29/23. Activity Staff Schedule for April 2023 documents no staff members on the schedule at all for activities on 4/03/23, 4/08/23 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 and record review, the facility failed to provide written notice to the Ombudsman for two (R3 and R16) of two residents reviewed for transfers in a sample of 25. Findings include: 1. R3's medical record documents R3 went to the hospital on 1/11/23 and 1/29/23. R3's medical record has no documentation the Ombudsman was notified of R3's transfer. On 4/13/23 at 10:47 AM, V5 Regional Nurse Consultant stated We don't notify the ombudsman of any discharges to the hospital, so I don't have any notification for (R3 or R16's) transfers. At that same time V5 Verified R3's medical record had no documentation the ombudsman was notified of a transfer. 2. R16's Progress Notes document R16 had a fall at 8:00am on 2/5/23, was sent to the hospital on 2/6/23; and returned to the facility on 2/10/23. The facility's Ombudsman Notification Log for February 2023 does not document R16's name or indicate transfer notification for R16 was given to the Ombudsman. The facility's Admission/Discharge To/From Report, dated 2/1/23 to 2/28/23, does not document R16's name to indicate R16 was…

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

Based on interview and record review, the facility failed to provide written notice of a bed hold for one (R3) of two residents reviewed for bed holds in a sample of 25. Findings include: R3's medical record documents R3 went to the hospital on 1/11/23 and 1/29/23. R3's medical record documents R3 is Medicare and Medicaid certified. R3's medical record has no documentation a bed hold was given to R3 or R3's representative. On 4/13/23 at 10:47 AM, V5 Regional Nurse Consultant stated We don't have a bed hold paper that was sent with (R3) when she went to the hospital on 1/11 and 1/29/23. At that same time, V5 Verified R3's medical record had no documentation a bed hold was given with the transfers on 1/11/23 and 1/29/23.

Based on record review and interview the facility failed to obtain a second required screening for one resident (R58) of four reviewed for PASARR (Preadmission Screening and Resident Review) in a total sample of 25. Findings Include: R58's Interagency Certification of Screening Results dated 1/17/2017 documents Screening indicated nursing facility services are agree appropriate and NOTE: Screening is valid for 90 days from the date of the screening: 01/17/2017 R58's Current (April 2023) Physician Order Sheet documents R58's Diagnosis as muscle weakness, hypertension, seizures, hypokalemia, hyperosmolality and hypernatremia, unspecified sequelae of unspecified cerebrovascular disease, unspecified bacterial pneumonia, streptococcal sepsis, anemia, selective mutism, chronic embolism, and thrombosis of unspecified vein, gastro-esophageal reflux disease without esophagitis fatigues, reduced mobility, dysphasia, anxiety, pseudobulbar affect, bipolar disorder and exposure to COVID. R58's Medical Record did not have any other PASARR or Interagency Certification Screening Results noted in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan to include Post Traumatic Stress Disorder (PTSD) for two resident (R78, R88) out of 22 residents revived for care plans in a sample of 25. Findings include: The facility's Trauma Informed Care policy dated 2023, documents 4. The facility will collaborate with resident trauma survivors and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as physiologists and mental health professionals) to develop and implement individualized care plan interventions. 10. In situations where trauma and survivor is reluctant to share their story, the facility will try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the rigger on the resident. 1. R88's medical record documents R88 admitted to the facility on [DATE] with a diagnosis of PTSD. R88's current care plan does not include…

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

Based on observation, interview and record review the facility failed to revise the pain management care plan for one resident (R47) of 17 residents reviewed for care plans in the sample of 25. Findings include: Facility Policy/Pain Management dated 2022 documents: In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. On 4/11/23 at 11:00am R47 was in bed and stated her left leg hurts when she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct ongoing scheduled pain assessments and re-evaluate one resident (R47) after increased complaints of pain of four residents reviewed for pain management in the sample of 25. Findings include: Facility Policy/Pain Management dated 2022 documents: In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain) Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess and identify the root cause, potential triggers and implement trauma-informed care for two residents (R78, R88) with a diagnosis of Post-Traumatic Stress Disorder (PTSD) out of three residents reviewed for mood and behavior in a sample of 25. Findings include: The facility's Trauma Informed Care policy dated 2023, documents Trauma-Informed Care: is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization .2. The facility will use a multi-pronged approach to identify a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for one resident (R33) with a diagnosis of dementia of five residents reviewed for unnecessary medications in the sample of 25. Findings include: Facility Policy/Use of Psychotropic Medication dated 2022 documents: The indications for use of any psychotropic drug will be documented in the medical record. For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: During the pharmacist's monthly medication regimen review; In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications and the resident's comprehensive plan of care. Use of…

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

Based on observation, interview and record review the facility failed to safely dispose of medications during medication pass. This failure had the potential to affect three residents (R36, R69, R95) reviewed during medication pass. Findings include: Facility Policy/Destruction of Unused Drugs documents: All unused, contaminated, or expired drugs shall be disposed of in accordance with state laws and regulations. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. Unused and unwanted medications should be removed from the storage area and secured until destroyed. A Non-Controlled Medication Destruction Record must be maintained for all non-controlled drugs destroyed and such a record must be verified by the consultant pharmacist. The sealed container must be maintained in a secure area in the pharmacy or in a locked cabinet in the medication room until transferred to the waste disposal service or the reverse distributor. On 4/12/23 at 11:25am V11, 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 observation, interview, and record review, the facility failed to ensure a resident had a bedside table for one (R77) of 25 residents reviewed for resident needs in a sample of 25. Findings include: R77's medical record documents she was admitted on [DATE]. On 4/11/23 at 11:55 AM, R77 was alert and oriented and had no overbed table in her room. R77 stated I have been here for a few weeks, I don't have an overbed table and would like one, I eat all three meals in my room per my request, I eat my meals off the chair (stationary chair pulled up next to side of bed), the meals aren't real comfortable to eat off the chair but that is all I have. I was told they do not have any other overbed tables for me to use. On 4/11/23 at 12:40pm, (R77) was eating her meal off her chair. On 4/11/23, 4/12/23, 4/13/23, and 4/14/23 CNA's/Certified Nurse Aides were observed charting in the hallway and dining room on over bed tables, and three over bed tables were in the physical therapy room on the same hallway as R77. 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.