Avenues At Royal Oak

Based on interview and record review, the facility failed to ensure that residents and their representatives were provided a clear, accurate, and understandable explanation of the arbitration agreement during the admission process, resulting in confusion and lack of informed consent for all residents reviewed. This failure has the potential to affect all 128 residents who reside in the facility.Findings include:The facility's undated Arbitration Agreement documents, Arbitration is an alternative means of resolving a dispute in place of court litigation. Binding Arbitration mean that both parties must comply with the arbitration decision, and that decision cannot be appeal. This agreement binds all parties, including, without limitation, any spouse, children or heirs of the resident, whose claims arise out of injuries, death because of alleged negligence, or wrongful act, but not intentional injury, and services rendered for any condition and arising out of the diagnosis, treatment, or care of the resident.The facility's CMS (Centers for Medicare and Medicaid Services) Long Term 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 observation, and interview, the facility failed to maintain a safe, clean, and comfortable environment for residents in A Wing, resulting in unsanitary conditions, structural disrepair, and the presence of black fuzzy discoloration on bathroom walls and standing water in multiple bathrooms for 46 of 46 residents (R1, R4, R14, R15, R16, R17, R19, R21, R22, R27, R28, R29, R31, R40, R42, R44, R45, R46, R48, R51, R52, R53, R56, R60, R62, R64, R70, R71, R73, R79, R81, R83, R84, R89, R96, R97, R103, R106, R107, R110, R113, R120, R125,R130, R131, and R132) reviewed for environment in the sample list of 74. Findings include: The facility's Cleaning-Sanitizing Bathing Equipment and Toilet Seats Policy revised 1/2018 documents housekeeping personnel are responsible for at least daily cleaning of bathing equipment, wipe down or scrub all surfaces with a soft brush, cleaning cloth or sponge and sanitizing agent to assure removal of organic matter and then completely rinse with clean water. The facility's Housekeeper Supervisor policy revised 7/2023 documents the primary purpose 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 provide privacy during gastrostomy cares/feeding for one of two residents (R27) reviewed for gastrostomy cares in a sample of 74.Findings Include:The Illinois Long Term Care Ombudsman Program Resident Rights Policy, Revised 11/18 documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. You have a right to privacy. Facility staff must respect your privacy when you are being examined or given care.R27's Physician Order sheet documents, Enteral Feeding Order, four times a day, every day.On 9/14/2025 at 12:43 PM, V11 (Registered Nurse) began gastrostomy cares to R27. R27's door was wide open, and R27's curtain was halfway closed. Various residents walked past R27's room and observed V11 performing R27's gastrostomy care.On 9/14/2025 at 1:00 PM, V11 confirmed she should have closed the curtain all the way or shut the door before beginning R27's cares.

Based on observation, interview, and record review the facility failed to ensure a call light was in reach for one of one resident (R63) reviewed for call lights in a sample of 74.Findings include: The facility's Call Light Policy, dated 10/2024, documents Purpose: To respond to residents' requests needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location.R63's Care Plan dated 9/24/24, documents, (R63) is usually unable to perform ADLS (Activities of Daily Livings) without weight bearing/hands on assist of one to two care givers or dependent for cares related to history of Stroke. This same plan of care documents R63 requires staff assistance with all ADLS and extensive assistance with two staff members and mechanical lift for transfers.On 9/14/2025 at 9:21 AM R63 was sitting in a high back wheelchair in his room…

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 allow a resident their preferred smoking method for one of three residents (R62) reviewed for smoking in a sample of 74. Findings Include:The Illinois Long Term Care Ombudsman Program Resident Rights Policy, Revised 11/18 documents, Your rights to dignity and respect, you have a right to make your own choices. R62's Smoking Safety Risk assessment dated [DATE] documents R62 smokes tobacco. This same assessment also documents R62 is not cognitively impaired, able to smoke, does not show potential for causing injury to self or others from smoking in unauthorized areas or careless use of smoking materials, has no history of hazardous behavior while smoking, follows facility smoking policy, and is on supervision during smoking times.R62's Smoking Progress Note dated 7/30/2025 and signed by V13 (Activity Director), documents (R62) does use tobacco. (R62) does not use an electronic cigarette or vaping device. (R62) is not interested in receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a residents personal preference and dignity was provided for 1 of 3 residents (R2) reviewed for resident rights in the sample of 8.The findings include:On 7/31/25 at 9:58 AM, R2 was in her room in bed on the locked psychiatric unit of the facility. R2 stated that she never said she was flicked in the eye or face by the nurse. R2 stated what she was upset about was that she was told she could not eat in the main dining room. V5 registered Nurse said she had to eat in the small dining room where the TV is at. R2 stated on Friday after she reported a possible suicide attempt for someone else, she was told she had to eat in the TV/small dining room and not the main dining room. R2 stated sitting in the TV room gives her panic attacks. When she told them that on Friday, they let her eat dinner in the main dining room. On Saturday at breakfast, she thought she would be okay to eat in the dining room; instead V5 made her sit in the TV room and left her…

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 interviews and record review, the facility's direct care staff failed to notify the abuse coordinator of an injury of unknown origin for one of four residents (R1) reviewed for abuse in a sample of eight.The findings include:R1's face sheet indicated an initial admission date of 03/01/2011 with a past medical history not limited to: paranoid schizophrenia, bipolar disorder, major depressive disorder, mood affective disorder, anxiety, anemia, pruritis, history of shock therapy, and long term (current) use of anticoagulants.R1's care plan indicated but not limited to: risk for injury related to limited dexterity and cognitive impairment and risk for falls with date initiated of 10/02/2023.R1's Minimum Data Set (MDS) section C for cognitive patterns dated 04/13/2025 indicated severe cognitive impairment. R1's skin condition report with effective date of 07/26/2025 submitted by V7 (Licensed Practical Nurse) documented bruising to R1's rear right thigh, chin, front left shoulder, and right front lower leg that were purple in color and a new/change in skin condition.Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the safety of a resident by not adequately assessing a resident for risk of falls, not assessing a resident for injury after a fall, and not properly transferring a resident off the floor after a fall incident for one of three residents (R1) reviewed for falls in the sample of eight.The findings include:R1's face sheet indicated initial admission date of 03/01/2011 with a past medical history not limited to: paranoid schizophrenia, bipolar disorder, major depressive disorder, mood affective disorder, anxiety, anemia, pruritis, history of shock therapy, and long term (current) use of anticoagulants.R1's care plan indicated but not limited to: risk for injury related to limited dexterity and cognitive impairment and, is a risk for falls both with date initiated of 10/02/2023; requires use of psychotropic medications (antidepressant, antipsychotic, anti-anxiety) to manage mood and/or behavior issues, date initiated 04/07/2024. R1's Minimum Data Set…

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 interviews and record review, the facility failed to protect two vulnerable residents by not preventing resident to resident physical abuse. This failure applied to two of four residents (R2, R4) reviewed for abuse in a sample of 6 that resulted in R2 being hit on the top of the head by R1 and R4 being slapped on the hand by R5. Findings include: 1. Final investigation report dated 04/25/2025 documented that R1 and R2 were both in the main hallway when alleged incident occurred. R2 was in wheelchair and cut in line in front of R1, who was standing. R2 touched R1's back as she was trying to get around her in the wheelchair. R1 instinctively turned and made contact to the top of R2's head. R1's face sheet indicated the resident admitted to the facility on [DATE] with a past medical history not limited to bipolar II disorder, anxiety disorder, post-traumatic stress disorder, and attention-deficit hyperactivity disorder. Brief Interview for Mental Status (BIMS) dated 05/20/2025 showed R1 has no cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect one of three residents (R2) from physical abuse by another resident, in a sample of seven. FINDINGS INCLUDE: The facility policy, Abuse Prevention and Reporting, dated (approved) 09/2024 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. The facility Report to State Office, dated 3/8/2025 at 6:00 A.M. and signed by V1/Administrator documents,(R3) alleges (he) was struck by another resident (R2). Injuries: 2 CM (Centimeter) laceration to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for one of three residents (R2) reviewed for PASARR screening, in the sample of 7. FINDINGS INCLUDE: The facility policy, Preadmission Screening and Annual Resident Review, dated (reviewed) 3/2024 directs staff, Annually and with any significant change of status, the facility will complete the PASARR Level 1 screen for those individuals identified per the Level 11 screen requiring specialized services. The facility will report any changes identified via the screen to the state mental health authority or the state intellectual disability authority promptly. The facility will refer all level 11 residents and all residents with newly evident or possible serious mental disorder for a level 11 review upon a significant change in status assessment to the State PASARR representative. R2's most current PASARR screen, 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 protect a high risk resident from physical abuse for one of three residents (R1) reviewed for abuse in a sample of three. Findings include: The facility's Abuse Prevention and Reporting policy, revised 09/2024, documents that the facility affirms the right of our resident it be free from abuse, neglect, exploitation, misappropriation, of property, deprivation of goods and services by staff or mistreatment. A resident to resident altercation should be reviewed as potential situation of abuse. Resident to resident altercations that include any willful action that results in physical injury, mental anguish or pain must be reported in accordance with regulations. R1's electronic medical record documents the following diagnosis: bipolar, anxiety, depression, attention deficit hyperactivity disorder, traumatic brain injury, insomnia, and pseudobulbar affect. R1's Abuse/Neglect Screening, dated 1/27/25, documents a score of 6, indicating R1 is a high risk for abuse. R1's current care plan documents that R1 is at high risk 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, record review and interview the facility failed to monitor food temperatures to ensure food was served at a palatable temperature. This failure has the potential to affect all residents that reside at the facility. Findings include: A facility policy last revised 09/2023 and titled Monitoring Food Temperatures for Meal Service documents, Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures. Procedure: 1. Prior to serving a meal, food temperatures will be taken and and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. 2 The temperature for each food item will be recorded on the Food Temperature Log. Foods that required a a corrective action (such as reheating) will have the new temperature recorded with a notation of the corrective action intervention. Resident Council Meeting notes dated November 21, 2024, document, 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 record review and interview the facility failed to ensure funds were available for 100 of 100 residents (R2, R4, R5, R7-R10, R12-R104) reviewed for personal funds in a sample of 104. Findings include: The facility's Resident Funds Policy, dated 3/2024, documents Resident Funds- Guidelines: This facility manages the personal funds of residents when such request is made by the resident. Access to Personal Funds: Residents should have access to petty cash on an ongoing basis and be able to arrange for access to larger funds. Although the facility need not maintain 100.00 dollars (50.00 dollars for Medicaid residents) per resident on its premises, it is expected to maintain petty cash on hand to honor resident requests. Banking hours shall be posted in a visible area and indicate where inquiries should be directed during the posted hours. Resident request for access to their funds should be honored by facility staff as soon as possible but not later than: The same day for amounts less than 100.00 dollars (50.00 dollars for Medicaid residents); Three banking days for amounts 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 report an allegation of employee to resident sexual abuse to the State Agency and to Law Enforcement of one resident (R1) of three residents reviewed for abuse. Findings include: Facility Policy/Abuse Prevention and Reporting dated 09/2024 documents: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Filing accurate and timely investigative reports. Sexual Abuse is non-consensual sexual contact of any type with a resident. Sexual Abuse includes, but is not limited to: Unwanted intimate touching of any kind especially of breasts or perineal area.\ Generally, sexual contact is nonconsensual if the resident either: Lacks ability to consent and/or does not want the contact to occur. Internal Reporting Requirements and Identification of Allegations: Upon learning of the report, the administrator 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.

Based on interview and record review the facility failed to protect one resident (R1) after an allegation of employee to resident sexual abuse was reported for three residents reviewed for abuse. Findings include: Facility Policy/Abuse Prevention and Reporting dated 09/2024 documents: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment and misappropriation of property. Protection of Residents: The facility will take steps to prevent potential abuse while the investigation is underway. Employees of the facility who have been accused of abuse, neglect, exploitation, mistreatment or misappropriation of resdient property will be removed from resdient contact immediately. The employee shall not be permitted to return to work until the results 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 observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 4 residents (R9) reviewed for abuse in the sample of 9. The findings include: R9's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, borderline personality disorder, other obesity due to excessive calories and polycystic ovarian syndrome. Her 9/2/24 quarterly assessment documents she is cognitively intact with verbal behaviors and other behaviors not directed at others to include verbal yelling out. On 11/2/24 at 11:10 AM, R9 stated she had concerns with her treatment from a night shift CNA (Certified Nursing Assistant), V15. R9 said a couple days ago she started her period for the first time in awhile so she was wearing her underwear to bed. R9 said she put on her call light during the night to use the bedpan, and V15 entered her room to assist her. She said when V15 asked her why she was wearing underwear, she told her about…

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 allegations of abuse were immediately reported to the administrator for 1 of 4 residents (R9) reviewed for abuse in the sample of 9. The findings include: R9's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, borderline personality disorder, other obesity due to excessive calories and polycystic ovarian syndrome. Her 9/2/24 quarterly assessment documents she is cognitively intact with verbal behaviors and other behaviors not directed at others to include verbal yelling out. On 11/2/24 at 11:10 AM, R9 stated she had concerns with her treatment from a night shift CNA (Certified Nursing Assistant), V15. R9 said a couple days ago she started her period for the first time in awhile so she was wearing her underwear to bed. R9 said she put on her call light during the night to use the bedpan, and V15 entered her room to assist her. She said when V15 asked her why she was wearing…

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

Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions and Contact Precautions throughout the facility to protect vulnerable residents and prevent the spread of multi-drug resistant organisms (MDROs). This failure has the potential to affect all 132 residents residing in the facility. Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, dated 7/13/23, documents Purpose: To reduce transmission of multidrug-resistant organisms. EBP should be used when contact precautions do not apply for residents with any of the following: Open wounds that require a dressing change, indwelling medical devices, infection or colonized with a MDRO. EBP requires use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for care that occurs within a resident's room, when high-contact resident care activities are bundled together. Outside of a resident's room, EBP should be followed when performing…

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 132 residents residing at the facility. Findings include: The facility's Antibiotic Stewardship Program policy (reviewed 12/12/18) documents the following: Purpose: to improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished by utilizing the Core Elements. Leadership Commitment: Demonstrates support and commitment for safe and appropriate antibiotic use. Accountability: Identify physicians, nursing and pharmacy leads responsible for overseeing antibiotic stewardship activities. Drug Expertise: Establish access to consultant pharmacists or other individuals with expertise or training in antibiotic stewardship. Action: Implement at least one policy or practice to improve antibiotic use.…

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 Infection Preventionist was adequately implementing and performing duties that accompany the position. This failure has the potential to affect all 132 residents residing at the facility. Findings include: The facility's Infection Preventionist Job Description documents the following: Qualifications: Must possess the ability to plan, organize, analyze, develop, implement and interpret the goals, objectives, policies, procedures, etc., of the Infection Control Program. This same job description documents, The Infection Preventionist is accountable for decreasing the incidence and transmission of infectious diseases between residents, staff, visitors and community. Through strategic planning, leadership and consultation, you will lead and direct a robust team in the identification and implementation of infection prevention goals and objectives throughout the facility. The Infection Preventionist reports to the Director of Nursing, Quality Assessment and Assurance Committee and partners with the Medical Director to…

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

Based on interview, observation and record review, the facility failed to ensure resident call lights were responded to in a timely manner for eight of 43 residents (R20, R37, R54, R55, R57, R63, R66 and R109) reviewed for call lights in the sample of 45. Findings include: Monthly Resident Council Meeting Minutes (dated June 2024) document the following concern: CNA's (Certified Nursing Assistant)- Third shift needs to answer call light quicker. On 09/24/24 from 09:15 AM - 10:30 AM, a group meeting was conducted with residents who attend Monthly Resident Council Meetings at the facility. All residents in attendance at the meeting, R37, R54, R55, R57, R63 and R66, verbalized concerns with excessive call light response times from facility staff. All residents stated it can take around 30 minutes to get someone to respond to call lights, especially after meals. R63 stated staff's response to call light times on third shift is way too long and has exceeded one hour on multiple occasions, especially for those residents who need extensive help. All residents present in the meeting stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Record Review and Interview, the facility failed to ensure residents electronic medical records and care plans matched their Physician's Order for Life-Sustaining Treatment (POLST) for Cardio-Pulmonary Resuscitation (CPR) code status for two of 32 residents (R42, R92) reviewed for Advanced Directives in the sample of 45. Findings include: The facility's Advanced Directive Policy, dated [DATE], documents Policy: The Patient Self Determination Act states that individuals have the right to make their own decisions, and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. The facility shall take all steps necessary to comply with state and federal legislation relating to advanced directives. 4. Any decision made by the resident shall be indicated in the chart in the manner easily understood by all staff. Advanced…

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 and implement a baseline care plan for one of two residents (R232) reviewed for new admission care plans, in a sample of 45. FINDINGS INCLUDE: The facility policy, Baseline Care Planning, dated (revised) 11/1/2017 directs staff, It is the policy of the (facility) to promptly assess and plan care for each resident admitted to the facility. A plan of care (Baseline Care Plan) shall be developed to include instructions needed to provide effective person-centered care to each resident, based on his/her initial assessment and the professional standards of quality of care, to serve as a functional guide in delivery of care until such time as a comprehensively plan is developed. R232's current Physician Order Sheet, dated September 2024 documents that R232 was admitted to the facility on [DATE] with the following diagnoses: Adjustment Disorder with Depressed Mood, Borderline Personality Disorder, Post-Traumatic Stress Disorder 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 hand hygiene was performed during wound care for one of four residents (R84) reviewed for Pressure ulcers in the sample of 45. Finding Include: The Facility's Preventative Skin Care Policy, dated 3/16/2023, documents, It is the facility's policy to provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly times four then will be reassessed at least quarterly and/or as needed. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two hours. Special mattresses and/or chair cushions will be used on any resident identified as being at high risk for potential skin breakdown. Encourage resident activity, when feasible. Use repositioning techniques and Range of Motion…

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

Based on interview, and record review, the facility failed to implement and follow through ROM (Range of Motion) exercises for residents with functional limited range of motion for one of five residents (R64) reviewed for limited mobility in the sample of 45. Findings include: The Facility's Restorative Nursing Programs policy, dated 4/2006, documents, It is the policy of (the facility) to facilitate the movements of individuals toward independence while helping them satisfy their needs by providing Restorative Nursing Programs. Goal of the Restorative Nursing Program is to assist a resident to reach and maintain his/her highest practicable physical, mental and psychosocial needs. Implementing the Program, Determine the setting to implement the plan. Consider the length of time, as well as the time of day involved for teaching. On 09/22/24, at 10:15 AM, R64 was in his wheelchair, able to tell me his name and repeat who I was. R64 yells to communicate. R64 cannot move his bilateral legs, and cannot move his arms, his hands were closed and balled up tight unable to release them. R64's…

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 an indwelling urinary catheter tubing was off the floor and urinary drainage bag was covered and failed to keep indwelling urinary catheter bag below a resident's bladder for one (R92) of two residents reviewed for indwelling urinary catheters in a sample of 45. Findings include: R92's Physician Orders, dated 9/24/24, documents R92 has a Physician order for an (indwelling) catheter. On 09/22/24 at 11:18 AM R92 was sitting in a recliner in the lounge area by south nurse's desk. R92's indwelling catheter was uncovered with no privacy bag and the indwelling catheter tubing and catheter bag was lying on the floor. On 9/22/24 at 11:50 AM V9/Licensed Practical nurse verified R92's indwelling catheter tubing and catheter bag should not be sitting on the floor and that R12's catheter bag should have a privacy bag over it. On 9/23/24 at 9:50 AM V6/Certified Nursing Assistant (CNA), V7/CNA, and V8/CNA were preparing to transfer R92 with a mechanical lift from R92's wheelchair to his bed. During the mechanical…

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 ongoing communication with the dialysis center and failed to develop a complete, comprehensive care plan for a resident receiving dialysis services for one of one resident (R233) reviewed for dialysis, in a sample of 45. FINDINGS INCLUDE: The unnamed, undated facility policy directs staff, It is the policy of this facility to provide coordination of care with the resident's dialysis provider. Procedure: Residents needing dialysis services will be admitted with the co-ordination of their dialysis provider off site with a predetermined schedule. The facility will review contracts to assure resident's needs are met while residing at the facility. The facility will co-ordinate care with the dialysis provider in developing an appropriate plan of care to include, but not limited to: Specific days of the week resident will attend dialysis; Any recommended medication schedule change; Meal or snack sent with resident.; Fluid restriction and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, Interview and Record Review, the facility failed to provide psychosocial therapies and psychiatric support services to resident with diagnosis of Adjustment Disorder and repeated emergency room visits for suicidal ideation's and depression for one of six residents (R102) reviewed for Behavioral Services in the sample of 45. Findings include: The facility's Facility Assessment, dated 9/20/24, documents Cares provided for the resident population include but are not limited to: Mental health and behavior; identify and implement interventions to help support individuals with anxiety, cognitive impairment, depression, PTSD (Post Traumatic Stress Disorder), and other psychiatric diagnosis. Support by group and individual therapies, and structured activities. In house psychiatric physician management. This assessment also documents the facility will provide therapy services including psychiatry. The facility's (undated) Social Service Assistant policy documents Job Summary: Assists the Social…

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 physical abuse for two (R1 and R2) of four residents reviewed for abuse in the sample of 12. Findings include: The facility's Abuse Prevention Program, dated 11/28/2016, documents This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The facility's Final Abuse Report, dated 6/10/24, submitted to State Agency on 6/15/24, documents an altercation occurred between R1 and R2 resulting in R2 receiving a black eye. This report documents: Reported to ADM (Administrator) that (R2) had discoloration to eye.…

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 physician order and have Speech Therapy services assess a resident's individual swallowing needs after a choking incident for two (R1 and R2) of three residents reviewed for accidents/incidents in a sample of three. Findings include: The facility Residents' Rights for People in Long-Term Care Facilities, dated 11/18, documents Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source. Your facility must provide services to keep your physical and mental health, at their highest practical levels. Facility Therapy Services Agreement, which began on 3/12/24 and signed on 3/13/24, documents Contractor will provide licensed Therapists in adequate training and number to provide Rehabilitation Services at the facility as needed by the facility patients. Contractor will provide Rehabilitation Services on weekends and holidays as clinically appropriate, and in accordance with a plan of care. Contractor will prepare treatment records and provide 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.

Based on Observation, Interview and Record Review, the facility failed to ensure Physical and Occupational Therapy services were provided to residents who have been determined to have the need for Physical and Occupational Therapy services for eleven of eleven residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11) reviewed for Therapy in the sample of eleven. Findings include: The facility's Facility Assessment, dated 2/7/24, documents Cares provided for the resident population include but are not limited to: Therapy- Physical Therapy, Occupational Therapy, Speech Therapy, music, crafts, management of supporting devices, splints and braces. This assessment also documents the following healthcare professionals and medical practitioners who will provide support and care for residents of the facility includes Therapy services. On 3/5/24 at 10:07 AM, V2 (Administrator in Training, trainee) stated he oversees daily functioning of the facility operations when V1(Administrator in Training) is away. V2 stated February 16th is the last day we had Physical, Occupational or Speech therapy 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 provide a sufficient number of staff and train a sufficient number of staff to care for and meet the behavioral needs of residents with mental and psychosocial disorders. These failures have the potential to affect all 131 residents residing within the facility. Findings include: The facility's Midnight Census form (dated 1-29-24) indicates that 131 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…

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 an electronic monitoring camera for one of three residents (R10) reviewed for resident rights in the sample of 76. Findings include: The Electronic Monitoring in Long-Term Care Facilities Illinois Long-Term Care Ombudsman Program Authorized Electronic Monitoring in Long-Term Care Facilities Act Public Act 99-043 date 12/2017 documents, The authorized electronic monitoring in long-term care facilities act provided a way for residents of long-term care facilities and their families to help ensure that residents receive the best care possible. The Illinois Attorney General's office worked closely with resident advocates and long-term care facility associations to create a framework that allows residents and their families to use cameras while protecting the privacy rights of others and ensuring there is no cost to facilities. Under the Law: A resident has the right to purchase and use an electronic monitoring device that records or broadcasts audio and video after providing notice to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide a written notice of a facility initiated discharge, including the reason for discharge, the location to where the resident is discharged , the regional Ombudsman's and the agency responsible for the protection and advocacy of individuals with a mental disorder contact information, or the resident's appeal rights to the resident, the resident's POA (Power of Attorney), and the Office of State Long-Term Care Ombudsman for one of three residents (R2) reviewed for notice of discharge in a sample of 76. Findings include: The facility's Transfer and Discharge Policy and Procedure policy (undated) documents, Involuntary transfers or discharges: Except for the case of late payment or nonpayment, the facility shall notify the resident and the residents family member, surrogate or representative of the transfer and the reasons for the transfer as stated in the clinical record. Notice of involuntary transfer or discharge shall be on the forms prescribed by…

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 responses, actions, and rationale taken regarding resident council concerns, grievance complaints, suggestions, and recommendations. These failures have the potential to affect all 135 residents residing in the facility. Findings include: The Facility Census and Conditions Report, dated 10/25/23, documents 135 Residents residing in the Facility. The Facility Administrator Job Description, undated, documents: Administrator is responsible for managing, planning, organizing, directing, coordinating and the physical management of the Facility in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; will manage and conduct business of the Facility license and certification at all times; and operate the Facility in compliance with all Federal and State rules and regulations; assure proper Facility and department operation through the implementation of the specified Quality Assurance Program; provide an…

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

Based on observation, interview, and record review the facility failed to ensure the Facility Survey Results were maintained, up to date and in a location accessibility for the Residents and visitors to review. This failure has the potential to affect all 135 residents residing in the facility. Findings include: The Facility Census and Condition Report, dated 10/25/23, documents 135 Residents residing in the Facility. The State Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised 11/18, documents that Residents have the right to see reports of all inspections by the (State Agency) from the last five years and the most recent review of your facility along with any plan that your facility gave to the surveyors saying how your facility plans to correct the problem. On 10/23/23 at 9:00 am, a black binder documenting the Facility's Survey Results,, was on a table in the front lobby entrance to the Facility. The Facility survey binder documents survey results dated January 2021 through January 2023. No previous or recent survey results were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment. This has the potential to affect all 135 residents in the Facility. Findings include: Facility Census and Conditions Report, date 10/25/23, documents 135 Residents residing in the Facility. Facility Resident Rights, revised 11/18, documents: that Residents have the right to complain to the Facility and get a prompt response; must treat Residents with dignity and respect, and care for Residents in a manner that promotes quality of life; and must be a safe, clean, comfortable, and homelike environment. The Facility Administrator Job Description, undated, documents: Administrator is responsible for managing, planning, organizing, directing, coordinating and the physical management of the Facility in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; will manage and conduct business 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 record review and interview the Facility failed to oversee, govern, and initiate programs for Quality Assurance Performance Improvement programs/plans and follow-up for the calendar year. This failure has the potential to affect all 135 residents who currently reside in the facility. Findings Include: Facility Census and Condition Report, dated 10/25/23, documents 135 Residents residing in the Facility. The Facility Administrator Job Description, undated, documents: Administrator is responsible for managing, planning, organizing, directing, coordinating and the physical management of the Facility in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; will manage and conduct business of the Facility license and certification at all times; and operate the Facility in compliance with all Federal and State rules and regulations; and assure proper Facility and department operation through the implementation of the specified Quality Assurance Program. The Facility's Quality…

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 conduct quarterly Quality Assurance/QA Performance Improvement meetings and failed to identify, monitor, and correct QA potential concerns for the last calendar year. This failure has the potential to affect all 135 residents who currently reside in the facility. Findings Include: Facility Census and Condition Report, dated 10/25/23, documents 135 Residents residing in the Facility. The Facility Administrator Job Description, undated, documents: Administrator is responsible for managing, planning, organizing, directing, coordinating and the physical management of the Facility in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; will manage and conduct business of the Facility license and certification at all times; and operate the Facility in compliance with all Federal and State rules and regulations; and assure proper Facility and department operation through the implementation of the specified Quality Assurance…

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 conduct quarterly Quality Assurance/QA Performance Improvement meetings and assure the required committee members were present for the last calendar year. This failure has the potential to affect all 135 residents who currently reside in the facility. Findings Include: Facility Census and Condition Report, dated 10/25/23, documents 135 Residents residing in the Facility. The Facility Administrator Job Description, undated, documents: Administrator is responsible for managing, planning, organizing, directing, coordinating and the physical management of the Facility in a way that the purpose of the Facility shall be maintained in accordance with all established practices, policies, laws and applicable State Regulations; will manage and conduct business of the Facility license and certification at all times; and operate the Facility in compliance with all Federal and State rules and regulations; and assure proper Facility and department operation through the implementation of the specified Quality Assurance Program. 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 perform a care plan meeting with a resident and revise a care plan following a fall, new onset of pain, use of an antipsychotic and target behaviors, and significant weight loss for six of 29 residents (R5, R24, R49, R117, R284, R285) reviewed for care plans in the sample of 40. Findings include: 1. R24's Physician's orders, dated 10/24/23, document that R24 has an order to receive Olanzapine (antipsychotic) 2.5 mg (milligrams) by mouth in the evening for the diagnosis of bipolar disorder. R24's care plan, dated 10/2/23, documents, The resident uses psychotropic medications related to behavior management. Disease process. R24's care plan has no documentation to include that R24 receives an antipsychotic nor the diagnosis or behaviors for the use of the antipsychotic. On 10/25/23 at 10:45 AM, V13 (Care Plan Coordinator) confirmed that R24's care plan is not revised to include that R24 is receiving an antipsychotic. 2. R49's Quarterly…

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 showers to a resident dependent on assistance with showering for one of one resident (R284) reviewed for ADL (Activities of Daily Living) assistance in the sample of 40. Findings include: On 10/23/23 at 10:23 AM, R284 was alert sitting on the side of her bed with her wheel walker sitting in front of her. R284's hair was disheveled with a wet like appearance to it. R284's right eye is completely closed surgically. R284 stated, I don't have a right eye and I'm practically blind in my left eye. I can see shadows and shapes. Look at this dirty hair! It's greasy and I stink. I haven't had a shower for over a week. I'm supposed to get a shower every Wednesday and Saturday on 2nd shift, and I haven't gotten one for at least a week. This is disgusting. I'm going to ask them if I can have one today, even if it isn't my shower day but I doubt they will give me one. They will have some kind of excuse. They always tell me they can't because…

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 document current Advance Directives and code status in the physician's orders and on the care plan for one resident (R233) of 27 residents reviewed for Advance Directives in the sample of 40. Findings include: Facility Policy/Advance Directives dated [DATE] documents: After confirming the accuracy of provided documents with the resident/responsible party, the document will be sent for appropriate signatures. No order for No Code or DNR shall be effective until the Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form is signed by resident/responsible party and physician order is received and documented. Any decision made by the resident shall be indicated in the chart in the manner easily understood by all staff. Those resident's indicating Do Not Attempt Resuscitation/DNR shall be recorded as a DNR. Code status shall be recorded on the resident's Physician Order Sheet. Staff must be aware of any requests for Medical Interventions shall…

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

Based on observation, interview, and record review the facility failed to ensure wrist restraints were applied according to manufacturer's safety guidelines and failed to evaluate bed rails. The facility also applied arm weights as restraints for one (R5) of two residents reviewed for physical restraints in the sample of 40. Findings include: The facility's Abuse Prevention Program, revised 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. The facility's limb restraint Manufacturer's Guidelines for the use of R5's wrist restraints documents in Application Instructions: Triangulation process; to restrict patient's range of motion: Separate the straps and attach at different points along the frame that moves with the patient, out of the patients reach, using quick-release…

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 develop a comprehensive assessment for the use of side rails and pain management for two of 29 residents (R233, R285) reviewed for care plans in the sample of 40. Findings include: The facility's Comprehensive Care Planning policy, dated 7/20/22, documents, It is the policy of the facility to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history, and preferences to develop a person centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. 1. On 10/22/23 at 08:17 AM, R285's bed had a full padded side rail up on the left side in the upright position, and a full padded side rail down on the right side. On 10/22/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify triggers, develop a Trauma Informed Care Plan and interventions for one resident (R112) identified with PTSD (Post Traumatic Stress Disorder) of 32 residents in the sample of 40. Findings include: Facility Policy/Trauma Informed Care dated 8/23/23 documents: Upon admission the SSD (Social Service Director) will review hospital discharge records and interview the resident or resident's representative to determine any history of trauma. If the resident is determined to have suffered a traumatic event, the SSD will discuss with the resident or resident's representative regarding potential triggers that may cause re-traumatization and interventions or preferences that eliminate or decrease triggers that may cause re-traumatization. The IDT (Interdisciplinary Team) will develop a resident centered care plan that will identify the stressor, triggers, clinical manifestations, and interventions to mitigate against re-traumatization. The IDT will…

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 narcotic pain medication was available as physician ordered for a resident with a new rib fracture for one of four residents (R285) reviewed for pain in the sample of 40. Findings include: The facility's Medication Administration policy, dated 11/18/17, documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit 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. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. 1. On 10/22/23 at 10:50 AM, R285 was alert and oriented sitting up in a wheelchair in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document behaviors to warrant the use of an antipsychotic and perform a GDR (Gradual Dose Reduction) for one of six residents (R24) reviewed for psychotropics in the sample of 40. Findings include: The facility's Psychotropic Medication Policy, dated 11/28/17, documents, Any resident receiving such medications shall have a psychiatric 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 cause the resident frightful distress. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavior interventions unless clinically contraindicated, in an effort to discontinue the drugs. Reductions shall be attempted at least twice in one year, unless the physician documents the need to maintain the resident regimen according to the Regulatory Guidelines for such. On 10/23/23 at 09:48 AM, R24 was alert…

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 medical records were not falsified for one of one resident (R284) reviewed for falsified records in the sample of 40. Findings include: The facility's Progressive Discipline Policy, no date, documents, The Administrator is responsible for monitoring supervisory actions to ensure that corrective discipline is both communicated and equally applied by them to all employees. Critical Offenses: These offenses are serious violations of rules, or employee's misconduct which justify immediate termination without regard to the employee's length of service or prior record of conduct. The Notice of Termination would be completed for qualifying offense. Examples of critical offenses include but are not limited to: Deliberate omission or falsification of significant information on: Records. R284's Shower/Abnormal Skin Report, dated 10/7/23, documents that R284 had a shower on this date. The report was signed by V19 (Certified Nursing Assistant) that she assisted R284 with the shower. R284's Shower/Abnormal Skin Report, 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 record review and interview the facility failed to develop a care plan to address a resident's behaviors for one of three residents reviewed for abuse in the sample of three. Findings include: The facility's Comprehensive Care Planning policy dated 7-20-22 documents a comprehensive care plan should be developed to reflect a resident's current medical, nursing, mental, and psychosocial needs and should describe a need/problem indicating approaches/interventions to be instituted to assist the resident in maintaining/receiving care in relation to the need/problem. V7's (Certified Nursing Assistant/CNA) written statement (undated) documents, (R1) called (V4/CNA) a f*g b*h in the dining room. R1's Care Plan dated 8-22-23 does not include a plan of care with interventions to address R1's verbal behaviors. On 9-8-23 at 10:07 AM V8 (Social Service Assistant) stated, (R1) has behaviors of yelling and cussing at staff when he is upset. On 9-8-23 at 11:30 AM V1 (Administrator) stated, The facility has not developed a care plan to address (R1's) behaviors.