Arcadia Care Kewanee

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with a diagnosis of Diabetes Mellitus was administered physician ordered insulin and blood glucose monitoring for one (R57) of three residents reviewed for medication administration out of a sample of 35.Findings include:The facility's Medication Administration Policy dated 1/2015 documents medications must be administered in accordance with a physician's order, the right resident, right medication, right dosage, right route, and right time. Documentation of medication administration is recorded on the Medication Administration Record.R57's Census Line documents R57 was admitted to the facility on [DATE].R57's Medical Diagnoses dated 12/11/25 documents Type 2 Diabetes Mellitus and Long-Term Insulin use.R57's MDS (Minimum Data set) dated 12/25/25 documents R57 is cognitively intact.R57's Physician Orders dated 12/11/25 documents Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Inject 30 unit subcutaneously…

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 follow a resident's prescribed diet for 1 of 3 residents (R3) reviewed for prescribed diets in the sample of 6.Findings include:On 7/26/25 at 11:55 AM, R2 was sitting in his wheelchair at the dining room table with his lunch tray in front of him. R2 had ham, mixed vegetables, creamed corn, dinner roll, butter, chocolate cream pie, water, and apple juice. R2 stated he just eats and drinks whatever they put in front of him. R2 confirmed that he was drinking apple juice that was given to him. The meal ticket next to R2 showed he was to have a carbohydrate controlled low concentrated sweet diet (LCS), regular texture, thin liquids and sugar free hot chocolate. V5 (Certified Nursing Assistant/CNA) came over to tie R2's clothing protector and his meal ticket was shown to her. V5 stated she just looks at the name on the meal ticket and gives the resident what is ordered. V5 stated the cook is the one that looks at the ticket and puts the food and beverages on the tray. On 7/26/25 at 12:10 PM, V4 (Dietary Manager)…

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

Based on observation, interview and record review, the facility failed to ensure a multidose insulin pen injector and a multidose tuberculin vial were labeled and dated when opened. These failures have the potential to affect all 56 residents residing in the facility. Findings include: The facility's Medication Storage Policy, dated 10/2024, documents Purpose: To ensure proper storage, labeling, and expiration dates of medications, biologicals, syringes, and needles. Guidelines: 5. Once any medication or biological package is opened, Facility should follow manufacturer supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. The Manufacturer Guidelines for Aplisol (Tuberculin), undated, documents Aplisol vials should be inspected visually for both particulate matter and discoloration prior to administration and discarded if either is seen. Vials in use for more than 30 days should be discarded. The facility's Pharmacy Audit…

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 with new diagnoses of mental illness after admission was referred to the state agency for a level II PASARR (Preadmission Screening and Resident Review) evaluation for one of one resident (R25) reviewed for PASARR screening in the sample of 35. Findings include: The facility's Preadmission Screening and Annual Resident Review (PASARR), dated 11/2018, documents It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in PASARR level I for all new and readmissions per requirements to determine if the individual meets the criterion for mental disorder (Severe Mental Illness/Severe Mental Disability), intellectual disability or related condition. Annually and with any significant change of status, the facility will complete the PASARR level one screen for those individuals identified per the Level II screen requiring specialized services. R25's current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete hand hygiene prior to and during urinary catheter care for one of two residents (R38) reviewed for indwelling urinary catheters in the sample of 35. Findings include: The facility's Urinary Catheter Care policy, dated 10/2024, documents Purpose: To establish guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Guidelines: 2. Hand hygiene shall be performed before and after touching any part of the urinary catheter drainage system. The facility's Infection Precaution Guidelines, dated 10/2024, documents Standard Precautions combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions (except sweat), mucous membranes may contain transmissible infectious agents. Standard Precautions consist of a group of infection prevention practices that apply to all residents, regardless of suspected 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.

Based on observation, interview, and record review the facility failed to obtain an order and follow a physician order for oxygen use and ensure an oxygen care plan was developed for two of three residents (R16 and R21) reviewed for oxygen in the sample of 35. Findings include: The Facility's Oxygen Concentration, dated 10/2024, documents Procedure: 1. Verify and understand the physician's order. 2. Know the flow rate and duration of use. The Facility's Medication Administration Policy, dated/revised 01/2015, states Medications must be administered in accordance with a physician's order, e.g. (for example), the right resident, right medication, right dosage, right route, and right time. The Facility's Comprehensive Care Plan Policy, dated/revised 11/2017, states The purpose of this policy is to develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will develop 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 have funds available for 18 of 18 residents (R1-R18) reviewed for personal funds in the sample of 18. Findings Include: The Facility's Resident Funds policy dated 04/2019 documents This facility manages the personal funds of residents when such a request is made by the resident. Resident requests for access to their funds should be honored by facility staff as soon as possible but no later than: The same day for amounts less than $100 ($50 for Medicaid residents); Three banking days for amounts of $100 ($50 for Medicaid residents) or more. On 12/11/24 V3 (Licensed Practical Nurse/MDS Coordinator) provided a list of residents whose money is managed by the facility. This list included R1-R18. On 12/11/24 at 9:00 AM R15 stated I have been asking for $150 out of my trust because I would like to buy some Christmas cards and other things for Christmas, and I've been told they are waiting on a check from corporate. They said that they do not have the money to give to me. On 12/11/24 at 9:30 AM R18 stated They told me that all of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the health care power of attorney of a change in condition for 2 residents (R5 and R19) of three reviewed for discharge in the sample of three. Findings Include: The Facility's Physician-Family Notification-Change in Condition policy dated 11/2018 documents the purpose of the policy to ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner, and if known, notify the resident's legal representative or an interested family member when there is B. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). D. A decision to transfer or discharge the resident…

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 notify the physician and resident's representative promptly after a fall with an injury for one of three residents (R1) reviewed for notification of changes in condition in the sample of four. Findings include: The facility's Notification for Change in Resident Condition or Status, undated, documents Policy: The facility and/or facility staff shall promptly notify appropriate individuals (Administrator, DON (Director of Nursing), Physician, Guardian, and HCPOA (Health Care Power of Attorney) of changes in the resident's medical/mental condition and/or status. Responsibility: Administrator, Director of Nursing, Charge Nurse. Procedure: 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: b. An accident or incident involving the resident. 2. The nurse supervisor/charge nurse will notify the DON, physician, and unless otherwise instructed by the resident the resident's next of kin or representative when the resident has any of the above-mentioned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to ensure physician ordered treatments, skin checks, and infection monitoring were completed for three of three residents (R1, R2, R3) reviewed for wounds in the sample of three. Findings include: The facility's Medication Administration policy dated 11/18/17 documents, Policy: Drugs and biologicals are administered only by physicians and licensed personnel. Definition: The complete act of administration entails removing and individual dose from a previously dispensed, properly labeled container (including a unity dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. Procedure: 19. Document any medication not administered for any reason by circling initials and documenting on the back of the MAR (Medication Administration Record) the date, the time, the medication and dosage, reason for omission and initials. The facility's Preventative…

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 program of a variety of activities for all residents. This failure has the potential to affect all 43 residents in the facility. Findings include: Facility Activity Policy dated 9/17 documents: It is the policy of the facility to provide an ongoing program of activities to meet the interests and the physical, mental, and psychosocial wellbeing of each resident. The program is under the Direction of an Activity Director, who shall have a specific planned program of group and individual activities based upon the resident's needs and interests. The facility will provide a program of activities which includes a combination of large and small group, one-to-one and self-directed activities; and a system that supports the development, implementation, and evaluation of the activities provided to the residents in the facility. All residents shall be offered the opportunity, and encouraged to participate in activities, but shall not be required to participate. For residents with no discernable…

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 qualified Activities professional to direct the provision of activities to all residents. This failure has the potential to affect all 43 residents in the facility. Findings include: Federal Form 671 dated 6/3/24 indicates there are 43 residents in the facility. Facility Job Summary/Activity Director (undated) documents: The Activity Director plans, schedules, and implements an ongoing program of activities designed to meet the physical, mental, and psychosocial needs of each resident. Residents are engaged in a meaningful, varied program of activities that meets the individual residents. The activities are conducted with individuals or in groups, according to the residents Plan of Care. The Activity Director completes the activity assessment for each resident and participates in developing the Interdisciplinary Care Plan. Qualifications: Completion of a State approved Basic Orientation Course will be required. Facility Activity Policy dated 9/17 documents: It is the policy of the facility to provide an ongoing…

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 perform registry verification for five Certified Nursing Assistants prior to hiring. These failures have the potential to affect all 43 residents residing in the facility. Findings include: On 6/5/24 at 2:00 pm, V1 (Administrator in Training) stated she does not have any documentation that the Nurse Aide Registry was checked for V10 CNA (Certified Nursing Assistant), V24 CNA, V25 CNA, V27 CNA, and V28 CNA prior to hiring for employment. V1 stated due to staffing problems she has not had anyone to do the verifications, does not have any documentation prior to January 2024, and is having to go back and do the checks herself. 1. V10 CNA was hired on 3/22/24 and Nurse Aide Registry was not checked until 6/4/24. 2. V24 CNA was hired on 5/15/24 and Nurse Aide Registry was not checked until 5/16/24. 3. V25 CNA was hired on 1/5/24 and Nurse Aide Registry was not checked until 6/4/24. 4. V27 CNA was hired on 10/25/23 and Nurse Aide Registry was not checked until 11/10/23. 5. V28 CNA was hired on 12/15/23 and Nurse Aide Registry 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 have qualified dietary staff. This has the potential to affect all 43 residents in the facility. Findings include: Facility Food Service Manager, revised 10/2020, documents Manages all aspects of the Food Service Department. Manages nutritional care of all residents in the facility. Must have or be willing to take the Dietary Managers Course. Must have passed the sanitation test or willing to take the course approved they the state for the facility within 60 days of hire. Certified Dietary Manager preferred. On 6/2/24 at 8:58 AM, V12 (Dietary Manager) verified the facility does not have a dietician employed full time. V12 also verified she is not certified as a dietary or food service manager, does not have a certification nationally recognized in food service management, is not currently enrolled in a course, does not have a degree in food service management, and started the position as the dietary manager in 2024, but was a dietary aid before. On 6/04/24 at 8:36 AM, V12 stated, We have a qualified dietician that comes 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 have an alternatives or always available menu posted for residents during mealtimes. This has the potential to affect all 43 residents in the facility. Findings include: On 6/2, 6/3, 6/4, and 6/5/24, the dining room had the meal posted with one alternative food choice posted on the meal board. No other food choices were posted for residents to choose from if they did not like the main meal, or the alternative meal choice option. The facility was unable to provide an alternative, or always available food menu. Facility Diet Type Report, dated 6/4/24, documents all 43 residents have diet orders. V12 confirmed all 43 residents have a diet ordered and eat from the kitchen. On 6/02/24 at 8:58 AM, V12 (Dietary Manager) verified they did not have other food options posted other than one alternative food choice which is always leftovers, and they did not have a menu or list of foods always available for the residents to choose from for meals posted. At that same time, V12 stated she did not know how residents would…

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 palatable food at lunch time on 6/3/24. This failure has the potential to affect all 43 residents who currently reside in the facility. Findings Include: The Facility's Menu documents that on 6/3/24 for lunch a pork fritter with gravy, scalloped potatoes, green beans, and peaches was served. On 6/3/24 at 12:00 PM R18 stated This food is disgusting. I am just going to eat my snacks I have in here (in resident's room). The food here is usually awful. Sometimes if we get (a cook) who knows how to cook it can be ok. But this (pork fritter) is over cooked and tasteless. On 6/3/24 at 12:05 PM R3 stated The meat is rubbery and difficult to cut. I have drowned it in gravy, and it is barely edible. The food here is a constant problem. I think they (facility) buy the cheapest food available whether it has taste or not. On 6/3/24 at 12:08 PM R6 stated Thank God I have snacks in my room. This (lunch) is disgusting. I am not eating that. R6 stated the food at the facility is hit and miss. R6 stated I don't think…

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 have a clean sanitary oven, failed to develop a cleaning schedule for the dietary department, and failed to have dishwasher detergent in the dish machine. This has the potential to affect all 43 residents in the facility. Findings include: Facility Ware-Washing- Dish machine, revised 10/2009, documents It is the policy that utensils and dishes washed by the mechanical dishwasher will be clean and sanitized. Facility Kitchen Sanitation, revised 10/2020, documents The Food Service Manager will monitor sanitation of the Dietary Department on a daily basis. The Food Service Manager will develop a cleaning schedule for the department and ensure that dietary employees complete cleaning tasks as scheduled. The Food Service Manager shall provide cleaning instructions for each area and piece of equipment in the kitchen and specify which chemical and personal protective equipment should be used for each task. Facility Cleaning Schedule, dated 10/2014, documents It is the policy to provide a system for determining 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 monitor active infections, failed to identify transmission-based precaution needs and failed to have Personal Protective Equipment (PPE) available to all staff. These failures have the potential to affect all 43 residents who reside in the facility. Findings include: The Facilities Infection Control Policy Surveillance and Monitoring last revised 5/2007 documents It is the policy of the facility to do routine surveillance and monitoring of the facility to determine compliance with work practices. The policy further documents Monitoring of the day-to-day operation of the infection control program will be conducted by the Director of Nursing (DON), Director of Nursing will determine and direct correct procedures necessary for the prevention of infections. The policy also states the DON will prepare the Infection Tracking Log on a monthly basis for quarterly presentation to the Quality assurance committee. The DON will ensure Isolation…

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 their Antibiotic Stewardship program was implemented. This failure has the potential to affect all 43 residents residing at the facility. Findings include: The facility's Antibiotic Stewardship Program policy dated 11/1/2017 documents the following: Assessing antimicrobial use is essential for determining antimicrobial use trends. Antimicrobial use assessment should be conducted regularly to measure progress of antimicrobial stewardship activities. After completing the assessment, the facility should be able to describe who is getting antibiotics and why. Additionally, the results are useful to identify gaps in communication, inconsistencies in documentation, and compliance with facility policies and evidence-based recommendations for antimicrobial prescribing. The policy further documents to address these issues Kewanee care home has developed an antibiotic stewardship program. Antibiotic stewardship is the act of using antibiotics appropriately that is, using them only when truly needed and using the right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a working overhead light in the bathroom for one (R20) of sixteen residents reviewed for environment in a sample of 43 residing in the facility. Findings include: Facility Maintenance Person, undated, documents The Maintenance Person maintains all building, equipment, systems and grounds in good, safe, and presentable condition. Regularly inspects and maintains electrical, signaling, and cooling and protection systems. Maintains furniture, fixtures, and furnishings in a clean, safe, attractive, and repaired manner. On 6/02/24 at 8:46 AM, R20's bathroom light switch was flipped on, and the light did not work. After flipping the light switch a few times the light came on but was dim and flickering. At that same time, R20 stated My bathroom light doesn't work, it has been a couple months, the maintenance guy knows and was gonna fix it, and I was told the ballast is bad. You have to flip the light switch about five times, and it…

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 report an injury of unknown injury to the local state agency for one resident (R11) of four reviewed for accidents in a total sample of 44. Findings Include: The Facility's Abuse Prevention Program dated 11/28/2016 documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our resident. The Facility's Abuse Prevention Program dated 11/28/2016 documents Regardless of the specific nature 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 interview and record review the facility failed to investigate an injury of unknown origin for one resident (R11) of four residents reviewed for accidents/injuries in a total sample of 44. Findings Include: The Facility's Abuse Prevention Program dated 11/28/2016 documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our resident. The Facility's Abuse Prevention Program dated 11/28/2016 documents Regardless of the specific nature of the…

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

Based on observation, interview, and record review the facility failed to implement a restorative walking program for one resident (R43) of three residents reviewed for mobility in a total sample of 44. Findings Include: R43's Physical Therapy discharge date d 5/30/2024 Summary documents Functional Maintenance: Ambulation Program Established/Trained: Recommend for patient to participate in walk to dine program to prevent decline in function and mobility. Throughout the survey R43 was never observed walking with his walker at any time. On 6/2/24 R43 stated I never walk anymore. They don't have enough help to do it (assist resident to walk). On 6/4/24 at 10:25 AM V2 (Director of Nursing) stated I didn't even know (R43) was on a walking program. To my knowledge he does not walk to or from meals. On 6/5/24 at 9:30 AM V11 (Certified Nurse Assistant) stated (R43) usually propels himself in his wheelchair to wherever he wants to go. He can walk with his walker in his room to toilet.

Based on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter tubing and collection bag were not placed on the floor to prevent infection for one (R40) of four residents reviewed for indwelling urinary catheter care in the sample of 44. Findings include: The facility's Catheter Care policy and procedure, dated 2/2018, documents Catheter care is provided daily and as needed to all residents who have an indwelling (urinary) catheter to reduce the incidence of infection. The Centers for Disease Control and Preventions documents Appropriate Urinary Catheter Use documents: Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. The Face Sheet for R40 includes the following diagnoses: Retention of Urine, Urinary Device and history of Sepsis (life threatening complication of an infection). The Order Summary Report for R40, dated 6/524, documents Urinary Catheter Care - Drainage Bag - Change every night shift every Saturday for catheter care related to Obstructive and Reflux Uropathy and Benign…

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 oxygen was being infused correctly, ensure oxygen tubing was dated, and ensure oxygen tubing was not resting on the floor for one (R40) of two residents reviewed for respiratory care in a sample of 44. Findings include: The facility's Oxygen Therapy policy and procedures, dated 8/2003, documents Oxygen therapy may be used provided there is a written order by the physician. The order must state liter flow per minute, mask or cannula, time frame. Change oxygen tubing/mask/cannula and/or tracheostomy mask on a weekly basis. Date tubing changes and document on the treatment sheet. The Face Sheet for R40, includes the following diagnoses: Acute Respiratory Failure with Hypoxia, COPD (Chronic Obstructive Pulmonary Disease) with acute exacerbation, Centrilobular Emphysema, and Oxygen Dependent. The Order Summary Report for R40, dated 6/5/24, documents the following physician orders as: Oxygen at 2L (liters) per NC (nasal cannula) as needed; Oxygen - tubing and humidifier change every night shift every…

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

Based on observation, interview and record review the facility failed to attempt non-pharmacological interventions prior to implementing psychotropic medications, failed to identify target behaviors for the use of antipsychotic medications, and failed to assess use psychotropic medications for two residents (R19, R39) of five residents reviewed for unnecessary medications in a sample list of 44. Findings include: The Facility Policy titled Psychotropic Medication Policy last revised on 11/28/2017 documents, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used without adequate indication for its use. Policy further documents the definition of an antipsychotic drug is A neuroleptic drug that is helpful in the treatment of Psychosis and has the capacity to ameliorate disorders. Any resident receiving such medications shall have a psychiatrics diagnosis or documented evidence of maladaptive behavior, which can be considered harmful to themselves or others, destructive to property, or if emotional problems exist which…

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

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5%. This failure affects two residents (R29, R35) of 10 residents reviewed for medication pass. This failure was the result of two medication errors out of 25 opportunities for a total medication error rate of 8%. Findings include: Facility Policy/Medication Administration dated 7/3/2013 documents: Medications must be identified using the six rights of administration: Right resident, Right drug, Right dose, Right time, Right route, Right documentation. Facility Policy/Oral Medication Administration dated 10/07 documents: To ensure the administration of oral medications is performed according to procedure. Procedure: Remove the correct amount of medication for the individual dose to be given at this time. 1.) On 6/3/24 at 11:20am V22 (Licensed Practical Nurse/LPN) administered Carbidopa-Levodopa (anti-Parkinson's) 25-100mg (milligram) one and one-half tablets for a total dosage of 37.5-150mg to R35. Medication card indicated to give 2.5 tablets for total dosage 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 interview and record review, the facility failed to provide a sufficient amount of direct care staff to provide timely care to dependent residents. This failure has the potential to affect all 54 residents currently residing at the facility. Findings include: The Resident Room Roster dated 2-21-24 indicates that 54 residents are currently residing in the facility. The facility's Nurse Staffing policy (undated) documents the following: It is the policy of (facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident. Nursing staff shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (State Agency). Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day, and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at…

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

Based on observation, interview, and record review, the facility failed to allow a resident to use her personal motorized wheelchair for one of three residents (R2) reviewed for resident rights in a sample of 12. Findings include: The Illinois Long-Term Care Ombudsman Program Resident's Rights for People in Long-term Care Facilities dated 11/2018 documents, Your personal property rights: You may keep and use your own property. The facility's Motorized Wheelchairs policy dated 1/09 documents, Policy: The facility will work to provide increased mobility and independence for all residents. Each resident will be evaluated for the need and safe use of motorized wheelchairs. Procedure: 1. Conduct an Illinois Department of Healthcare and Family Services (HFS) evaluation for each new admission within 30 days of admission and then quarterly. Initial evaluations will be completed by the facility staff familiar with the resident. 2. Obtain consent from the resident and/or POA (Power of Attorney) for a full motorized wheelchair assessment. 3. Arrange a full motorized wheelchair assessment, as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide a resident's power of attorney health and medical records upon request for one of three residents (R3) reviewed for resident rights in the sample of 12. Findings Include: The Illinois Long-Term Care Ombudsman Program Resident's Rights for People in Long-term Care Facilities Resident Rights Handbook dated 11/2018 documents Your facility must allow you to see your records within 24 hours of your request (excluding weekends and holidays). You may purchase a copy of part or all of your records at a reasonable copy fee within two working days of your request. On 2/21/22 at 12:10 PM, V13 (R3's Power of Attorney) stated that R3 was hospitalized on [DATE] after suffering a stroke. V13 stated I have been talking to the facility about getting (R3's) records. They have not been helpful at getting me this information. We have asked for referrals to be sent so she can be transferred to another facility and (the facility) hasn't sent them the needed…

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 a resident's physician of a new laboratory result for one of three residents (R3) reviewed for Physician Notification in the sampled of 12. Findings include: The facility's Notification of Change in Resident Condition or Status policy, dated 10/12/05, documents The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, Director of Nursing, Physician, Guardian, Health Care Power of Attorney, etcetera) of changes in the resident's medical/mental condition and or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been; A need to alter the resident's medical treatment significantly, Abnormal lab findings. R3's Physician Order Sheet, dated 11/1/23-2/29/24, documents R3 has a laboratory order for PT (Prothrombin)/INR (International Standardized Ratio for clotting in the blood) one time only related to Personal History of Pulmonary Embolism, Personal History of other Venous Thrombosis and Embolism, until…

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 the interdisciplinary team and the residents' representatives were invited and attended care plan conferences for two of three residents (R1 and R2) reviewed for care planning in the sample of 12. Findings include: The facility's Comprehensive Care Planning policy dated 11-1-17 documents, The Care Plan Conference (meeting) shall be held as necessary to communicate major revisions to the Comprehensive Care plan and minimally with every Comprehensive MDS (Minimum Data Set) completed. The facility shall make effort that the conference: a. Be attended by a representative from each discipline involved in the resident's care as possible. b. Be attended by the resident. c. Be attended by a representative of the resident's choice if that person so chooses to attend. 1. R1's BIMS (Brief Interview Mental Status) dated 11/23/2023 documents R1 is Cognitively Intact. R1's Medical Record dated 2-23-23 through 2-23-24 does not include documentation of R1's Power of Attorney/POA (V6) being invited to R1's care plan meetings. On…

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

Based on observation, interview and record review, the facility failed to maintain transmission-based precautions for two residents (R4 and R5) out of five residents reviewed for infection control during an outbreak of COVID-19. This failure has the potential affect four COVID-19 negative residents (R6, R7, R8 and R9) residing on the same hall. Findings include: The facility's COVID-19 Control Measures policy revised 5/19/32 documents 2. All HCP (Health Care Providers) are to perform hand hygiene upon entrance to the facility, prior to entering a resident room, when exiting a resident's room, and after direct contact with residents or potentially contaminated surfaces. The facility's resident COVID-19 testing tracking sheet documents R4 and R5 tested positive for COVID-19 on 11/28/23 and are currently on transmission-based precautions (TBP) for COVID-19. R6, R7, R8 and R9 all tested negative for COIVD-19 and are currently not on TBP. R4 and R5's medical record dated 11/28/23, both document they are on transmission-based precautions for 10 days due to positive COVID-19 test. The…

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

Based on observation, interview, and record review, the facility failed to provide sufficient staff to care for dependent residents. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The Facility Assessment Tool, dated 10/2/23, documents, Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs. Staff assignments and continuity of care is determined on current census and resident acuity of care needed. The facility's Daily Placement Sheet, dated 9/16/23, documents that for 1st shift the facility staffed two nurses and four CNAs. The sheet documents that for 2nd shift the facility staffed two nurses and four CNAs. The facility's Daily Placement Sheet, dated 9/25/23, documents that for 1st shift the facility staffed two nurses and three CNAs (Certified Nursing Assistant). An additional CNA worked 2.5 hours during 1st shift as well. The sheet documents that for 2nd shift the facility staffed two nurses and four CNAs. The facility's Daily…

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 answer call lights in a timely manner for 5 of 11 residents (R3-R7) reviewed for call lights in the sample of 11. Findings include: On 10/3/23 at 8:35 a.m. R3, R4, R5, and R6's call lights were on. On 10/3/23 at 8:38 a.m., R7's call light turned on, and R3-R6's call lights remained on. On 10/3/23 at 8:51 a.m., R5's call light was turned off. However, R3, R4, R6, and R7's call lights remained on. R5's call light was on for a total of 16 minutes. On 10/3/23 at 8:54 a.m., R3 and R6's call lights were turned off. R5's call light was back on, and R4 and R7's call lights remained on. R3 and R6's call lights were on for a total of 19 minutes. On 10/3/23 at 9:00 a.m., R5 and R7's call lights were turned off. R4's call light remained on. R5's call light was on for an additional six minutes, and R7's call light was on for a total of 22 minutes. On 10/3/23 at 9:02 a.m., R4's call light was turned off. R4's call light was on for a total of 27 minutes. On 10/3/23 at 9:12 a.m., R3 was alert sitting up in his recliner with a blanket over…

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 staff a full-time Director of Nursing/DON. This failure has the potential to affect all 60 Residents residing in the Facility. Findings include: Facility Census Roster, dated 9/7/23, documents 60 Residents residing in the Facility. V2's (Registered Nurse/Interim Director of Nursing) Job Description, dated 8/2/23, documents: Job Summary is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current Federal, State and Local Standards, guidelines and regulations that govern our Facility and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality of care is maintained at all times; participate in surveys made by authorized government agencies; assist to plan, develop, organize, implement, evaluate and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations and guidelines that govern the long-term care facility; and determine 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.