Marshall Rehab & Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect residents' right to be free from physical abuse of R3 by R2 and R4. This failure affects three (R2,R3,R4) of five residents reviewed for abuse on the sample list of eight. Findings include: 1.) R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status (BIMS) score of two out of a possible 15 indicating, severe cognitive impairment R2's Brief Interview of Mental Status (BIMS) assessment dated [DATE] documents R2 has a score of 15 out of a possible 15, which indicates no cognitive impairment. The facility Illinois Department of Public Health (IDPH) Final Report Incident Date: 2/23/2025 signed by V1, Administrator/Abuse Prevention Coordinator, documents the following: Summary; Received report that (R2) resident, struck (R3) resident. They were immediately separated without any apparent injuries (right cheek injury documented below) . R2's Nursing Progress Note dated 02/23/2025 at 12:30 pm, and signed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to remove R2, the perpetrator of physical abuse, from direct access with R2's vulnerable, dependent, non-verbal roommate R6. This failure affects two (R2,R6) of five residents reviewed for abuse on the sample list of eight. Findings include: R2's Brief Interview of Mental Status (BIMS) assessment dated [DATE] documents R2 has a score of 15 out of a possible 15, which indicates no cognitive impairment. R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status (BIMS) score of two out of a possible 15 indicating, severe cognitive impairment R6, MDS dated [DATE] documents R6 has severe cognitive impairment and is totally dependent of staff for all activities of daily living and does not ambulate R6's Diagnoses List last updated 01/16/25 documents the following: Cerebral Palsy, Quadriplegia, Unspecified, Metabolic Encephalopathy, Adjustment Disorder With Anxiety, Major Depressive Disorder Recurrent, Unspecified, 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 maintain complete and accurate medical records for two (R3,R4) of five residents reviewed for abuse on the sample list of eight. Findings include: 1.) R2's Nursing Progress Note dated 02/23/2025 at 12:30 pm, and signed by V6, Licensed Practical Nurse (LPN), documents the following: Note Text : Resident has been up to the nursing desk several times calling (V20, Family Member) and (V22, Family Member). No one answered the phone. Resident (R2) is becoming angry. Another resident sitting buy (by) the assignment board (R3), and he (R2) became physically aggressive with her (R3). Separated the two (R2 and R3). Assessed resident (R3) for any injuries, she has a red mark on her right upper cheek. Took v/s (vital signs) and assisted her to bed to relax. The DON (Director of Nursing) and the Administrator (V1, Abuse Prevention Coordinator) was (were) notified. R3's Nursing Progress Note dated 02/23/2025 at 5:24 pm is the only documentation in R3's chart that refers to R3's reddened facial area and does not mention the physical abuse…

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, facility staff failed to immediately report an allegation of staff to resident physical and verbal abuse to the facility administrator. This failure affects one resident (R1) of four reviewed for abuse in the sample of four. Findings include: The facility abuse prevention policy (2022) documents the facility will report all allegations of abuse within required timeframes pursuant to Federal and State statutes. The Code of Federal Regulations ( 483.12, 10/1/2023) documents: (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to…

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

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 53 in the facility. Findings include: On 4/9/2024 at 10:58AM, V8 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V8 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V8 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V8 reported the facility dietician does not work full-time in the facility. V8 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education 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 and interview, the facility failed to prevent direct cross-contamination of stored food and failed to maintain sanitary food storage areas. This failure has the potential to affect all 53 residents residing in the facility. Findings include: 1. On 4/9/2024 at 11:05AM, three wire shelving sections located in the kitchen walk-in cooler were partially covered with a gray-colored, fuzzy biological growth resembling mold. Boxes of food items, pans of prepared food, and jugs of milk were stored directly on these shelving racks. 2. On 4/9/2024 at 11:21AM, the facility walk-in freezer evaporator/condenser supply lines were leaking accumulated condensation onto boxes of food stored below on shelving. The leak had dripped directly into a fully open box of frozen green beans, partially covering the product. At this time, V8 (Dietary Manager) was present and observed the box of green beans. When asked if the ice on the green beans was condensation that had leaked from the above evaporator/condenser supply lines, V8 replied yes. On 4/12/2024 at 11:50AM, V8 reported food 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 observation, interview, and record review, the facility failed to ensure residents' rights to dignified activities of daily living. This failure affects six residents (R11, R14, R15, R16, R31, and R48) of six reviewed for dignity on the sample list of 35. Findings include: 1.) On 4/09/2024 at 12:30PM, five tables were pushed together in a row, at the center of the facility dining room with residents seated around the perimeter of the tables. Facility staff began serving lunch meals to the residents seated at the tables at 12:30PM, with residents seated at the same table receiving lunch meals within five minutes of each other. R11, R14, and R48 were all seated at the center table waiting for lunch to arrive while watching other residents eat lunch. R11, R14, and R48 did not receive a meal until 1:20PM, fifty minutes after the first meal was served to the adjoined tables. V10 (Activities Aide) was present and reported residents are supposed to eat lunch at 12:30PM. On 4/10/2024 at 12:45PM, no residents…

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 repeatedly to adequately supervise a resident (R40) at risk for self harm, and failed to document a resident (R159) fall into the facility's risk management system, initiate neurological checks, conduct a fall investigation, determine a root cause, and implement a specific fall intervention to aid in future fall prevention. These failures affect two of five residents (R40, and R159) reviewed for accidents/supervision on the sample list of 35. Findings include: 1.) R40's Current (multiple dates) Diagnoses Sheet documents the following diagnoses: Unspecified Dementia , Unspecified Severity With Psychotic Disturbance, and Unspecified Dementia, Moderate With Anxiety R40's Minimum Data Set, dated [DATE] documents R40 has severe cognitive impairment and uses a wheelchair for mobility. R40's Care Plan dated 04/04/24 documents the following: I currently have an alteration in my behavior status r/t (related to) Anxiety, Depression, Res (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 interview and record review, the facility failed to provide residents food at an appetizing temperature for four of four resident ( R11, R12, R18, and R31) reviewed for palatable meals on the sample list of 35. Finding include: R11, R12, R18 and R31's Current, Minimum Data Sets document R11, R12 R18 and R31 all have Brief Interview of Mental Status scores of 15 out of a possible 15, indicating they have no cognitive impairment. On 4/10/24 at 10:00 am during a resident group meeting, R11, R12, R18 and R31 their meals were often served late, up to one and a half hours past the scheduled meal time, resulting in hot food being served cold. All residents stated there has not been cold food served since state surveyors arrived in the building 4/9/24. On 4/10/24 at 11:30 am V8, Dietary Manager (DM) stated V8 DM Inherited a lot of kitchen problems when he started as DM two weeks ago. V8, DM stated All the hall trays are delivered to the halls first. We use a disc at the bottom and a cover over the top of the plate to keep the food hot. There have been a lot of complaints. The food…

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

Based on interview and record review the facility failed to provide bedtime snacks for four of five of four residents (R11, R12, R18 and R31) reviewed for bedtime snacks on the sample of 35. Findings include: R11, R12, R18 and R31's Current, Minimum Data Sets document the following: R11, R12 R18 and R31 all have Brief Interview of Mental Status scores of 15 out of a possible 15, indicating they have no cognitive impairment. On 4/9/24 at 10:00 during a resident group meeting, R11, R12, R18 and R31 stated snacks are not stocked daily or offered at bedtime. The facility sometimes puts the snack cart in the linen room and not at the nurses station, so the resident can't get snacks on their own. R12 and R31 both added they have Diabetics Mellitus and need to have a snack available so their blood sugar level doesn't drop. On 4/10/24 at 11:30 am V8, Dietary Manager stated There should be no problem with snacks at bedtime or between meals. The snack carts are taken to the nurses station, filled on each unit, each shift. I don't know if the snack carts are being put in the linen room. I had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow-up with physician regarding laboratory results for R40, and failed to ensure only licensed personnel administer medications for R10. R10 and R40 are two of 22 residents reviewed for the provision of skilled care/services on the sample list of 35. Findings include: 1.) R40's Current (multiple dates) Diagnoses Sheet documents the following diagnoses: Unspecified Dementia , Unspecified Severity With Psychotic Disturbance, and Unspecified Dementia, Moderate With Anxiety. R40's Minimum Data Set, dated [DATE] documents R40 has severe cognitive impairment. R40's Nursing Progress Note dated 03/20/2024 at 3:12 pm documents the following: Note Text: Called and spoke with (V25, Physician's) nurse about aggressive behavior on (of) resident (R40) toward staff, (V25) ordered (laboratory blood test) CBC (Complete Blood Count) and Ferritin (protein that helps the body store iron) level, (and) continue same meds (medications) (,) if (R40) continues…

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 timely incontinence care for a resident. This failure affects one resident (R15) reviewed for incontinence care on the sample list of 35. Findings include R15's Minimum Data Set (MDS) dated [DATE] documents R15's Brief Interview of Mental Status (BIMs)score as 12 out of a possible 15, indicating moderate cognitive impairment, on the day of assessment. (interviews of staff documented below indicate R15 is cognitively intact and reliable). The same MDS documents R15 has limited range of motion of bilateral upper and lower extremities, and is occasionally incontinent of bowel and bladder. R15's Physician Orders Sheet documents R15 is taking Furosemide (medication to help reduce the build-up of fluid in the body, and increases the production of urine) 40 milligrams daily, for the diagnoses of Shortness of Breath and Edema. R15's Care Plan dated 04/09/24 documents the following: R15 currently has an alteration to her ability to care for herself 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 follow a physician ordered pressure ulcer treatment and implement pressure ulcer interventions for one (R10) of two residents reviewed for Pressure Ulcers on the sample list of 35. Findings Include: R10's undated Electronic Medical Record (EMR) documents medical diagnoses of Paraplegia, Retention of Urine, Need for Assistance with Personal Care, Left Ischium Stage 4 Pressure Ulcer, Right Gluteal Stage 4 Pressure Ulcer, Right Heel Stage 4 Pressure Ulcer and Muscle Weakness. R10's Minimum Data Set (MDS) dated [DATE] documents R10 as cognitively intact. This same MDS documents R10 as requiring maximum assistance for personal dressing, bathing and is dependent on staff for bed mobility. R10's Physician Order Sheet (POS) dated April 2024 documents physician orders to cleanse R10's Left Ischium with wound cleanser, apply thin layer of Hydrogel then cover with bordered gauze dressing daily and as needed. This same POS documents a physician order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to check the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to administration of medication and enteral feeding for one (R37) out of one resident reviewed for PEG tubes in a sample list of 35 residents. Findings include: R37's undated Face Sheet documents medical diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Aphasia, Cerebrovascular Disease and Dystonia. R37's Minimum Data Set (MDS) dated [DATE] documents R37 as severely cognitively impaired. R37's Care Plan intervention dated 2/12/24 instructs staff to check for Percutaneous Endoscopic Gastrostomy (PEG) tube placement and gastric contents/residual volume per facility protocol and record. R37's Physician Order Sheet (POS) dated April 2024 documents a physician order starting 3/7/24 to administer Jevity 1.5 calorie at (55 milliliter/hour). Check for placement and residual amount prior to administration. This same POS…

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, change, date and maintain respiratory equipment according to physician orders and facility policy. This failure affected three of three residents (R8, R22. and R31) on the sample list of 35. Findings include: 1.) R8's Physician Order Sheet (POS) dated 4/9/24 documents the following: O2 (Oxygen) at (administer) 4L (four liters per minute) PRN (as needed), if sat (blood oxygen saturation) below 85 '(Notify Physician)', every 15 minutes as needed for SOB (Shortness of Breath). The respiratory administration device is not documented. R8's same POS documents: Change Humidifier Bottle (with) date and time on bottle of (sic) change every night shift every 7 day (s) for Oxygen (sic) use refillable humidifier bottle change date and time on bottle of change (sic). R8's same POS documents R8 is on Hospice end of life care. On 4/9/24 at 12:00 pm, V28, R8's Family Member was seated at R8's bedside. R8 was asleep with an oxygen nasal cannula…

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, record review and interview the facility failed to ensure the dignity of four (R1, R5, R6, R8) residents out of five residents reviewed for dignity in a sample list of nine residents. Findings include: 1.) R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. This same MDS documents R6 as requiring moderate assistance for mobility and transfers. R6's Careplan initiated 11/27/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as moderately cognitively impaired. This same MDS documents R5 requires moderate assistance for mobility and transfers. R5's Careplan dated 10/4/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. On 3/3/24 at 10:20 AM V2 Director of Nurses (DON) stated V4 (R1's) family member was yelling at V19 Social Service Director (SSD). V2 stated V19 SSD came to get V2 DON to help resolve V4's concerns. V2 stated V2 and V19 both walked back to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to serve foods that are palatable to four (R1, R2, R4, R7) residents out of five residents reviewed for meal services in a sample list of nine residents. Findings include: 1.) R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact. On 3/2/24 at 12:15 PM R7 sitting in a wheelchair in room with lunch tray on bedside table in front of him. R7's lunch plate held two slices of dry ham, a small portion of mixed vegetables, a small portion of yams and a small portion of chocolate pudding. R7 stated The food is awful. This ham is so tough and dry. I can't even eat it. I tried to cut it with my fork but couldn't get through it. I guess I will just pick it up and see if I can rip it apart with my teeth. Wish me luck. It is like a hockey puck. This is what I guess prison food is like. 2.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. On 3/2/24 at 12:10 PM R1 sitting in recliner chair in room. R1's lunch…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to report an allegation verbal abuse of two (R5, R6) residents out of four residents reviewed for Abuse in a sample list of nine residents. Findings include: The facility policy dated 2022 titled 'The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure' documents individuals must report alleged violations, whether it was oral or in writing, to the Administrator or other designated facility representative and the facility must report the alleged violation to the State Survey Agency. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as cognitively intact. This same MDS documents R6 as requiring moderate assistance for mobility and transfers. R6's Careplan initiated 11/27/2023 does not include a focus area, goal nor interventions for R1's risk of Abuse. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as moderately cognitively impaired. This same MDS documents R5 requires moderate assistance for mobility 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 report an allegation of employee to resident (R1) physical abuse to the State Agency. R1 is one of three residents reviewed for abuse in the sample of three. Findings include: R1's Diagnosis Sheet (current) includes the following diagnoses: Anxiety, Major Depression, Urinary Retention, Atrial Fibrillation and Atrial Flutter. R1's Physician Order Sheet dated February 2024 includes an order for Apixaban (anticoagulant) 2.5 milligrams twice a day. R1's Progress Notes document the following: 2/13/24 at 3:32 pm Created 2/14/24 at 3:56 pm - Late Entry: CNA (Certified Nursing Assistant) reported bruise to (R1's) right upper arm. I (V9 Registered Nurse) assessed bruise it was purple in color measuring 5 centimeters (cm) by 4 cm with scattered minimal brushing surrounding the large bruised area. (R1) reports that a CNA from previous day shift was rough when rolling (R1) for care. (R1) states (R1) doesn't feel like (R1) was in any harm from the CNA. (R1) states that it was just one CNA in room at time of incident. 2/15/24 at 11:48…

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, record review and interview the facility failed to provide a clean, homelike environment for two (R5, R7) of seven residents reviewed for the physical environment in a sample list of seven residents. Findings include: The undated Illinois Long-Term Care Residents' Rights for People in Long Term Care Facilities handout documents residents have the right to a facility that is safe, clean, comfortable and homelike. Resident Council Minutes dated November 28, 2023 documents New business: some residents expressed that soiled incontinence briefs are being left in trash cans in their rooms and bathrooms. Action taken: concern form given to (V2) Director of Nurses (DON). Resident Council Minutes dated December 26, 2023 documents Old business: last month (11/28/23) residents expressed soiled incontinence briefs are sometimes being left in trash cans in residents rooms. Action taken: concern form given to (V2) Director of Nurses (DO). (V2) response: staff will be inserviced about leaving soiled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an injury of unknown origin to the State Agency for one (R2) resident out of three residents reviewed for skin alterations in a sample list of seven residents. Findings include: R2's undated Medical Diagnosis List documents medical diagnoses of Alzheimer's Disease, Muscle Weakness, Need for Assistance with Personal Care, Cognitive Communication Deficit, Dysphagia and history of Focal Traumatic Brain Injury without Loss of Consciousness. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring maximum assistance with personal hygiene, bed mobility, toileting dressing, toileting and uses a wheelchair. R2's Weekly Skin assessment dated [DATE] does not document any abnormalities/bruises to R2's skin. R2's Risk Management dated 1/8/24 documents R2 has a bruise on Right mid back measuring 14.0 centimeters (cm) long x 12.0 cm wide and a bruise on Right Lower Back measuring 3.5 cm…

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 dishwashing machine was operating as designed in a manner to sanitize dishes and wares, failed to properly thaw meats to protect ready to eat foods from meat juice dripping, failed to protect frozen foods from exposure to air and from leakage of foreign substances in the freezer, and failed to utilize clean utensils to access bulk food items. These failures have the potential to affect all 52 residents residing in the facility. Findings include: 1. On 5/30/23 at 10:10 am, V12, Dietary Aid, was actively operating the facility's dishwashing machine by placing soiled dishes, cups, glasses, utensils and cooking wares into one side of the machine, operating the machine through a wash and rinse cycle, then removing the same food service wares from the opposite side of the machine. The temperature gauge on the dishwashing machine was displaying an internal temperature of 120 degrees Fahrenheit (F). When asked if the dishwashing machine was a high temperature sanitizer or a chlorine sanitizer, V12 replied,…

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 include the required infection preventionist in 2 of five quarterly meetings. This failure has the potential to affect all 52 residents residing in the facility. Findings include: The facility-provided sign-in sheets for their quarterly Quality Assurance (QA) meetings were dated 4/13/22, 7/13/22, 10/19/22, 1/20/23, and 4/21/23. The QA meetings dated 4/13/22 and 4/21/23 did not document the attendance of any Infection Preventionist identified by the facility as V18 (former) Assistant Director of Nursing, and V3 Regional Nurse Consultant. On 6/1/23 at 10:52 am, V1, Administrator, stated, This isn't a fun conversation to have but the meeting on 4/21/23 we did not have an Infection Preventionist at the meeting. The meeting from 4/13/22 was before my time here so I have to rely on those employees who were here at that time and they tell me they were in a transition period between (V18 and V3), but unfortunately I am not able to confirm that we had an Infection Preventionist at that meeting. On 6/2/23 at 10:20 am, when…

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 protect the privacy of a resident by failing to obtain consent for in room videography for one (R48) of 24 residents reviewed for privacy from a total sample list of 24. Findings include: R48's undated face sheet documents that R48 is his own power of attorney for healthcare. On 5/30/23 at 11:23AM, on 5/31/23 at 2:00PM, and on 6/1/23 at 9:00 AM a video/audio monitor was on R48's bedside table in his resident room. On 5/30/23 at 11:30AM, on 5/31/23 at 2:10 PM and on 6/1/23 at 9:05 AM, the video/audio receiver for R48's video/audio monitor was at the C/D nurse's station. On 5/31/23 at 1:00PM, V9 CNA stated, They put a camera on (R48) to try to catch him before he falls. R48's fall care plan does not document R48 having a video/audio monitor for any purpose. On 6/01/23 8:45 AM at R48 was sitting in his room in a wheel chair. R48 stated that he didn't know that he had a camera in his room. R48 then asked what the camera was used for. The facility provided Resident's Rights for People in Long-term Care Facilities…

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 accurately encode a resident's minimum data set with regards to tobacco use. This failure affects one resident (R49) out of four reviewed for accident hazards on the sample list of 24. Findings include: On 5/30/23 at 11:42 am, the facility-provided list of resident smokers (undated) documents R49 as one of the resident smokers. On 5/30/23 at 2:04 pm, R49 stated, Yes, I smoke, regular cigarettes, not vaporizing. R49's Nurse Notes dated 1/30/23, 5/21/23, and 5/28/23 document (R49) off unit and outside to smoke. R49's care plan focus area dated 2/16/23 documents, (R49) is a smoker. R49's Minimum Data Sets dated 3/13/23, 3/13/23 modified, and 4/1/23 document under section J1300, for the question current tobacco use, the response is coded 0 for no. On 6/1/23 at 1:36 pm, V4, Minimum Data Set (MDS) and Care Plan Coordinator, stated, (R49) is a smoker, (R49's) care plan says she is a smoker, and all through (R49's) nurses notes it is documented she is a smoker. V4 then confirmed R49's MDSs documented R49 as no current tobacco 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 observation, interview, and record review, the facility failed to effectively sanitize dishes, failed to maintain sanitary food cooler areas, failed to prevent the potential for cross-contamination of food from physical contaminants, and failed to properly store bulk food items. These failures have the potential to affect all 49 residents in the facility. Findings include: 1. On 3/22/2022 at 10:45AM, the kitchen mechanical dishwasher sanitizer bucket was completely empty. At 12:38PM, V7 (cook) was washing dishes at the dishwasher and the chemical sanitizer bucket remained empty. The dishwashing water was tested by Illinois Department of Public Health test strip after the sanitizing portion of the wash cycle was complete and measured zero sanitizer was present. The manufacturer dishwashing requirements were posted on the side of the machine and documented a sanitizer concentration of 50 parts per million was required, at a minimum, to achieve effective dish sanitation. V9 (cook) was present with V7 and both were unaware if the kitchen mechanical dishwasher required chemical…

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 R145 was not subjected to physical abuse and mental abuse by R36. R145 is one of four residents reviewed for abuse on the sample list of 29. Findings Include: R36's assessment sheet Brief Interview of Mental Status (BIMS) dated 3/22/22 documents R36's BIMS score as 14 out of possible 15, which reflects no cognitive impairment. R145's Minimum Data Set, dated [DATE] documents R145 BIMS score as 11 out of possible 15, which reflects moderate cognitive impairment. The facility Incident Investigation Report dated 3/16/22 documents the following: Administrator (V1, Administrator/ Abuse Prevention Coordinator) received report that a resident (R36) 'dumped' a bowl of salad on the lap of another resident (R145) and walked out of the dining room. The staff (unidentified) stated that it appeared like he (R36) was walking over to talk to the other resident (R145). R36's Nurse Progress Note dated 3/16/2022 at 1:43 pm, written by V5, Registered Nurse (RN)…

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

Based on observation, interview, and record review, the facility failed to prevent involuntary seclusion by preventing a cognitively intact resident's free movement to the outside of the facility. This failure affects one resident (R36) of three reviewed for resident rights in the sample of 29 residents. Findings include: R36's Brief Interview of Mental Status (BIMS) dated 3/22/22 documents R36's BIMS score as 14 out of possible 15, reflecting no cognitive impairment. The facility Policy and Procedure, Signing Out for LOA (Leave of Absence) dated revised November 5, 2019 documents the following: Purpose To ensure staff have knowledge of residents that are out of the facility. Procedure 1. Each resident leaving the premises (excluding transfers/discharges) must be signed out. The facility Sign Out Sheet-When Taking a Resident Off Grounds or Going For a Walk documents R36 signed himself out of the facility on 3/19/22 at 6:45 pm. R36's Nursing Progress Note dated 3/19/2022 at 8:00 PM documents the following: Note Text: Resident this evening was upset he could not smoke a cigarette. He…

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 operationalize their abuse prevention policy by failing to recognize involuntary seclusion, and physical/mental abuse. This failure affects two of four residents (R36 and R145) reviewed for abuse on the sample list of 29. Findings include: The Residents Right To Freedom from Abuse, Neglect, and Exploitation Policy and Procedure dated 2020 states PURPOSE To ensure that all of (facility) residents are free from abuse, neglect, misappropriation of their property, and exploitation. POLICY The Facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. 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 policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, 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 record review and interview the facility failed to report allegations of physical and mental abuse to the State Survey Agency (Illinois Department of Public Health) in a timely manner, within the two hour required time frame. This failure affects one of four residents (R145) reviewed for abuse on the sample list of 29. Findings include: The facility Incident Report Form-IDPH (Illinois Department of Public Health) Notification form documents an interaction occurred 3/16/22 between R36 and R145. This facility incident report is dated 3/24/22. An Addendum facsimile cover sheet dated 3/25/22 at 10:33 am, to the Incident Report Form-IDPH Notification form documents Addendum to Initial Report, Incident Date 3/16/22. To clarify the interaction between residents (R36) and (R145). It was alleged that (R36) approached (R145) and dumped a bowl of food from a bowl onto him (R145). He (R36) also made a statement the following day,How did you like that food on you yesterday?. Investigation continues. On 3/23/22 at 4:35 pm R36 confirmed he intentionally threw food on R145. R36 stated he…

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, observation and interview, the facility failed to complete a thorough abuse investigation related to physical and mental abuse of R145 by R36. This failure resulted in R36 having full access to R145 who resided in an adjoining room. R145 is one of four residents reviewed for abuse on the sample list of 29. Findings include: On 3/22/22 at 3:45 pm R36 was seated in a wheel chair next to R36's bed. An eight foot wide corridor extended from the foot of R36's bed, 15 feet. The eight foot wide, 15 foot length corridor lead into R145's bedroom. On 3/25/22 at 10:30 am, V5, Registered Nurse stated V5 was in the dining room (on 3/16/22) when R36 physically abused R145 by pouring food in R145's lap. V5 stated she watched R36 walk back from R145's table with an empty bowl in his hands, while R145 was upset and had food in his lap. V5 stated V5 immediately reported the incident to V1 Administrator. V5 reviewed V5's incident (physical abuse allegation) witness statement, written by V1, Administrator. V5 stated The witness statement is correct but important details I (V5)…

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 observation, the facility failed to maintain a resident bathroom in a repaired and functional condition. This failure affects one resident (R20) reviewed for bathrooms in the sample of 29. Findings include: On 3/22/2022 at 1:58 PM, R20 reported having a bathroom in poor condition. R20's bathroom had extensive wallboard damage in the lower portions of the wall around the toilet, with about six feet of the flexible baseboard missing at the wall and floor junction. Another portion of baseboard was curling free from wall and directly in the way of toilet use. The walls around the toilet were damaged severely and crumbling with the wall missing portions. The toilet paper dispenser was missing the roller bar which was located in a pile of accumulated debris located behind the toilet basin. R20 reported the bathroom condition has been the same for a year.