Palm Garden Of Mattoon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect resident's right to be free from resident-to-resident verbal abuse. This failure affected one of six residents (R1) reviewed for abuse on the sample list of six. Findings Include:The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program Policy, dated April 2021, documents that each resident has the right to be free from abuse, including but not limited to verbal abuse.R2's Medical Diagnoses list, dated April 2026, documents that R2 is diagnosed with Major Depressive Disorder and Generalized Anxiety.R2's Minimum Data Set (MDS), dated [DATE], documents that R4 is cognitively intact, has bilateral lower extremity impairment, and uses an electric wheelchair for mobility.R2's Care Plan, dated 4/16/26, documents that R2 has the potential to be verbally aggressive related to mental and emotional illness. R2 exhibits inappropriate social behaviors, including the use of racial slurs, racist comments, and offensive gestures,…

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 initiate an elopement care plan for three (R37, R39, R40) residents out of four residents reviewed for elopement in a sample list of 40 residents. Findings include:1.R40's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Disorganized Schizophrenia, Anxiety, Major Depressive Disorder, Psychotic disorder with Delusions, Mild Intellectual Disabilities and unsteady on Feet. R40's Minimum Data Set (MDS) dated [DATE] documents R40 as severely cognitively impaired. R40's Elopement Risk assessment dated [DATE] documents R40 as being a high risk for elopement. R40's Elopement care plan was initiated 3/30/26. This same care plan did not include a focus area, goal nor interventions prior to 3/30/26 for R40's high risk for elopement. 2.R37's Minimum Data Set (MDS) dated [DATE] documents R37 as cognitively intact. R37's Elopement Risk Evaluation 2/12/26 documents R37 as a high risk for elopement. R37's Elopement care plan was initiated…

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 Licensed Nurses and Certified Nursing Assistants staff to meet the residents' needs for safety and quality of care. This failure has the potential to affect all 94 residents residing in the facility. Findings Include: The Facility assessment dated [DATE] documents an average daily census of 80-85 residents. The facility's goal is to maintain sufficient staffing to ensure an adequate number of qualified staff are available to meet each resident's needs.The Daily Nursing Schedule for 1/24/26 and 1/25/26 documents that on the night shift of 1/24/26 there was one nurse and one Certified Nursing Assistant (CNA) assigned to the front half of the building. On the day shift of 1/25/26, there was only one nurse in the building until 11:00 AM, when a second nurse arrived.On 1/29/26 at 8:45 AM, V37 (Licensed Practical Nurse/LPN) stated she was the front hall nurse on the night shift of 1/24/26. V37 stated she was alone in the front…

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 full time Certified Dietary Manager (CDM). This failure has the potential to affect all 94 residents residing in the facility. Findings include: The facility daily midnight roster dated 1/20/26 documents 94 residents resided in the facility.From 1/21/26 through 1/23/26, at various times of the day, V3 (Certified Food Protection Manager/CFPM), was observed educating kitchen staff, providing direction to dietary staff, and assisting with meal preparation and service to residents.From 1/27/26 through 1/29/26, the facility did not have a Certified Dietary Manager (CDM) employed or onsite.On 1/21/26 at 2:10 PM, V3 (CFPM) stated she is not a Certified Dietary Manager. V3 stated she has not started any classes and is not enrolled in a CDM program.On 1/23/26 at 2:00 PM, V27 (Regional Registered Nurse), stated the facility does not have a CDM. V27 stated V3 (CFPM) was serving as the acting dietary manager. V27 stated she was unsure whether there was a policy requiring the facility to have a CDM. V27 stated 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 maintain sanitary conditions during food preparation by dietary staff not wearing gloves and improperly applied hairnet during meal service. This failure has the potential to affect all 94 residents residing in the facility. Findings include:The facility's daily midnight roster dated 1/20/26 documents that 94 residents resided in the facility.The facility's weekly menu titled Week Three documents pancakes were scheduled to be served at the breakfast meal on 1/21/26.On 1/20/26 at 10:35 a.m., V6 (Dietary Aide) was observed pulling apart frozen pancakes with her bare hands in preparation for the 1/21/26 breakfast meal. After separating the pancakes, V6 placed them on a large sheet pan. V6 was not wearing gloves. V6 was wearing an oversized down winter coat while preparing the pancakes, and the sleeves of the coat made direct contact with multiple pancakes. V6 was wearing a hair net that did not fully cover all of her hair. V6 did not wash her hands prior to preparing the pancakes.On 1/20/26 at 10:40 a.m., V6…

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 a clean, homelike environment for four (R2, R52, R56, R77) out of five reviewed for physical environment in a sample list of 39 residents.Findings include:The facility was unable to provide any documentation of maintenance requests or completion reports for repairs requested or completed.On 1/20/26 at 11:25 AM, R2's wall next to her closet showed a large area of dents and scratches measuring approximately three feet wide by one foot tall. R2 did not have a closet door in place.On 1/20/26 at 11:38 AM, R52's closet did not have a door. The wall behind R52's dresser had five nails protruding approximately one inch from the wall.On 1/20/26 at 11:40 AM, R56's wall next to the head of her bed showed multiple scratches and dents covering an area approximately two feet wide by one foot tall.On 1/27/26 at 10:15 AM, R56 stated she would like her wall to be repaired. R56 stated, I always like a room to look neat and well taken care of.On 1/28/26 at 9:15 AM, V45 (Maintenance Assistant) stated there is no process in…

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

Based on observation, interview, and record review, the facility failed to provide services to protect resident dignity by leaving a urinary collection device uncovered in public view. This failure affects one resident (R88) out of five reviewed for urinary catheters on the sample list of 39.Findings include: On 1/22/26 at 12:49 PM, R88 was seated in a wheelchair in her own room with the door open. R88 had a urinary collection bag positioned on the right armrest of her wheelchair. R88's urinary collection bag contained approximately 100 cubic centimeters of yellow urine. R88's urinary collection bag was not covered, leaving the bag and contents clearly visible to anyone walking in the hallway. On 1/22/26 at 12:49 PM, R88 stated her dignity was all but lost in a nursing home as she received catheter and perineal cleaning from facility staff which would necessitate her laying on the bed with her legs wide open. R88 stated that when she went out of the facility, she would place her urinary collection bag in her purse to keep it from being in public view. R88 further stated when 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident (R81) from misappropriation of personal property by another resident (R74). This failure affects two residents (R74 and R81) out of six reviewed for misappropriation on the sample list of 39.Findings include: On 1/20/26 at 4:05 PM, R74 freely admitted he had picked up cigarettes and vape cartridges that did not belong to him. R74 stated the facility nursing staff keep smoking materials at the nurses' station and place them on the counter when it is time to smoke. R74 further stated he walked up to the nurses' station counter, observed cigarettes and vape cartridges without names on them, and picked them up. R74 also stated his own cigarettes and vape cartridges had gone missing.R74's Care Plan, initiated on 12/16/25, documents behavioral problems related to misappropriation of property belonging to others (vapes, lighters, and smoking materials).R74's Minimum Data Set (MDS) assessment dated [DATE] documents R74 is cognitively intact,…

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 all allegations of misappropriation of resident's personal property to the state surveying agency. This failure affects two residents (R74 and R81) out of six reviewed for misappropriation on the sample list of 39.Findings include:On 1/20/26 at 4:05 PM, R74 stated he had picked up smoking materials, including cigarettes and vape cartridges, that did not belong to him. R74 also stated his own cigarettes and vape cartridges had gone missing.R74's Care Plan, initiated on 12/16/25, documents behavioral problems related to misappropriation of property belonging to others (vapes, lighters, and smoking materials).On 1/21/26 at 1:24 PM, V1 (Administrator) stated there had been allegations of R74 taking other residents' cigarettes and vape cartridges. V1 stated she had been told by regional corporate staff that if the facility retrieved the items at the same time they were taken, it was not considered theft. V1 stated she did not report the allegations of misappropriation to the state surveying agency based on 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 interview and record review the facility failed to allow one (R11) resident the opportunity to choose a destination facility in his involuntary discharge process out of three residents reviewed for discharges in a sample list of 39 residents.Findings include: R11's undated Face Sheet documents R11 was admitted to the facility on [DATE].R11's Electronic Medical Record (EMR) documents medical diagnoses of paraplegia, moderate protein-calorie malnutrition, thoracic spinal cord injury (T7-T10), opioid dependence, neuromuscular dysfunction of the bladder, chronic pain, traumatic brain injury, history of urinary tract infection (UTI), neurogenic bowel, and tobacco use.R11's Minimum Data Set (MDS) dated [DATE] documents R11 is cognitively intact.R11's Involuntary discharge date d 12/1/25 documents R11 would be transferred to another facility located in Illinois.On 1/20/26 at 11:30 AM, R11 stated the facility was kicking him out because he had been aggressive toward staff. R11 stated he occasionally yelled 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 complete an accurate Minimum Data Set (MDS) assessment for three of four residents (R7, R10, R93) reviewed for Resident Assessments on the sample list of 39. Findings Include: 1. R7's MDS dated [DATE], Section N documents R7 receives insulin. R7's Physician Order Sheet (POS) dated December 2025 does not include insulin. 2. R10's MDS dated [DATE], Section N documents R10 receives insulin. R10's Physician Order Sheet (POS) dated December 2025 does not include insulin. 3. R93's MDS dated [DATE], Section N documents R93 receives insulin. R93's Physician Order Sheet (POS) dated December 2025 does not include insulin. On 1/28/2026 at 11:28 AM, V27 (Regional Clinical Nurse) confirmed R7's 12/15/25 MDS, R10's 11/13/25 MDS, and R93's 10/2/25 MDS were coded incorrectly when insulin was documented for each of these residents who in fact did not receive insulin.

Based on interview and record review, the facility failed to obtain or renew short-term Pre-admission Screening and Record Review (PASRR) prior to the expiration date (R9 and R81), and failed to obtain a revised PASRR for a resident diagnosed with severe mental illnesses whose PASRR did not include mental health diagnoses (R31). This failure affects three residents (R9, R31, and R81) out of nine reviewed for Pre-admission Screening on the sample list of 39.Findings include: 1. R31's Census Detail printed 1/20/26 documents R31 was admitted to the facility 7/23/25. R31's Diagnoses List printed 1/20/26 documents R31 was admitted to the facility with medical diagnoses including Schizophrenia, Auditory and Visual Hallucinations, Intellectual Disabilities, Suicidal Ideations, Bipolar Disorder, Depression, Anxiety, and adjustment disorder. R31's PASRR Level 2 dated 6/30/25 documents R31 was excluded from the Level 2 PASRR process due to not having any severe mental illness diagnosis. This PASRR documented R31 was not diagnosed with a serious mental illness (SMI). This PASRR documented…

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 services to maintain or increase a resident's range of motion. This failure affected one of three residents (R10) reviewed for Range of Motion on the sample list of 39. Findings include:The facility's Restorative Nursing Services policy dated July 2017 documents residents will receive restorative nursing care as needed to help promote optimal safety and independence.On 1/20/26 at 1:15 PM, R10 stated that although he prefers to remain in bed most of the time, he would like staff assistance with range-of-motion and strengthening exercises to maintain the strength he still has. R10 stated staff do not ask him to participate in any restorative range-of-motion programs.R10's Minimum Data Set (MDS) dated [DATE] documents R10 is cognitively intact.R10's Physician Order Sheet (POS) dated January 2026 documents diagnoses of adult failure to thrive, lack of coordination, reduced mobility, heart failure, chronic obstructive pulmonary disease,…

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 protect one resident's (R88) respiratory mask from potential cross-contamination, and failed to obtain appropriate physician orders for two residents (R9 and R10) to include required pressures for operation. This failure affects three residents (R9, R10, and R88) out of three reviewed for respiratory equipment on the sample list of 39.Findings include:1. R88's Census Detail printed 1/28/26 and Diagnoses List printed 1/23/26 document R88 was admitted to the facility on [DATE] with medical diagnoses including Acute and Chronic Respiratory Failure with Hypercapnia (elevated carbon dioxide levels), Chronic Congestive Heart Failure, Morbid Obesity with Alveolar Hypoventilation (lungs do not expand enough to fill adequately), Insomnia, and Obstructive Sleep Apnea (stops breathing when asleep).R88's Physician Order Sheet printed 1/23/26 documents R88 is to use the BIPAP ventilator while sleeping, with the inspiratory pressure set at 14 and 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 obtain informed consent for use of bilateral bed rails. The facility also failed to safely and securely install bed rails and failed to maintain safe and secure bed rails for one of six residents (R7) reviewed for accident hazards on the sample list of 39. Findings Include: The facility's Bed Safety and Bed Rails policy dated August 2022 documents that bed rails must be properly installed. To use bed rails, the facility must obtain informed consent.R7's Medical Diagnoses List dated January 2026 documents R7 is diagnosed with Chronic Obstructive Pulmonary Disease, Fractured Left Tibia, Disorder of Muscles, Lack of Coordination, Gait Abnormalities, Muscle Wasting, Phantom Limb Syndrome, and Right Above-the-Knee Amputation.R7's Physician Order Sheet dated January 2026 documents a physician order for a left half side rail in the up position while in bed to enhance bed mobility. Staff are to check the positioning and functioning of the device.R7's Bed Rail Transfer Bar Consent dated 2/7/25 documents R7 provided…

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 needed behavioral health services for community re-integration. This failure affects one resident (R74) out of one reviewed for behavioral health services on the sample list of 39.Findings include:R74's Census Detail printed 1/23/26 documents R74 was admitted to the facility on [DATE].R74's Diagnoses List printed 1/23/26 documents R74 has medical diagnoses including Borderline Personality Disorder, Suicidal Ideation, Anxiety, Bipolar Disorder, Major Recurrent Depression, Post-Traumatic Stress Disorder, Cocaine Abuse, and Nicotine Dependence.R74's Care Plan dated 6/11/25 documents R74 is independent in meeting his emotional, intellectual, physical, and social needs. R74's Care Plan dated 6/18/25 documents R74 is usually able to perform his activities of daily living (ADLs) independently or with supervision. The Care Plan dated 6/18/25 also documents R74's goal to return home or to the community. Interventions for this goal include…

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

Based on observation, interview, and record review, the facility failed to employ a qualified Psychiatric Rehabilitation Services Director (PRSD). This failure affects one resident (R74) out of one reviewed for behavioral health services on the sample list of 39.Findings include:On 1/20/26 at 3:29 PM, R74 was in his room on the facility's locked unit reserved for residents with serious mental illness and behavioral health needs.On 1/20/26 at 3:29 PM, R74 stated facility staff wanted to kick him out of the facility and that he wanted to speak with the Administrator (V1) to get the situation clarified.R74's Diagnoses List printed 1/23/26 documents R74 has medical diagnoses including Borderline Personality Disorder, Suicidal Ideation, Anxiety, Bipolar Disorder, Major Recurrent Depression, Post-Traumatic Stress Disorder, Cocaine Abuse, and Nicotine Dependence.R74's Care Plan dated 6/11/25 documents R74 is independent in meeting his emotional, intellectual, physical, and social needs. R74's Care Plan dated 6/18/25 documents R74 is usually able to perform activities of daily living (ADLs)…

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 adequate portion sizes and failed to provide food that is palatable for three (R11, R81, R93) out of three residents reviewed for dining services in a sample list of 39 residents.Findings include:The facility's daily Midnight Census dated 1/20/26 documents that 94 residents resided in the facility.R11's Minimum Data Set (MDS) dated [DATE] documents R11 as cognitively intact.R81's Minimum Data Set (MDS) dated [DATE] documents R81 as cognitively intact.R93's Minimum Data Set (MDS) dated [DATE] documents R93 as cognitively intact.On 1/20/26 at 10:32 a.m., V4 (Cook) prepared residents' lunches. V4 used a premeasured scoop to place chili into bowls for residents. V4 was observed scraping the bottom of the pan of chili to serve residents. The chili appeared very thick, with no liquid visible in the serving pan. V4 stated there were no residents who did not eat solid foods.On 1/20/26 at 10:58 a.m., V5 (Dietary Aide) moved an entire cart 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 use the services of a Registered Nurse (RN) for at least eight consecutive hours a per day. This failure has the potential to affect all 98 residents in the facility.Findings Include: Facility Nursing Staff Daily Assignment Sheets reviewed from 11/1/25 through 11/28/25 documented seven days (11/1, 11/2, 11/8, 11/9, 11/15, 11/22, 11/23) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 11/28/25 at 2:34 PM V2 (Director of Nurses) confirmed the facility did not have eight hours of Registered Nurse coverage every day, especially on the weekends when administration staff aren't at the facility to cover. V2 also confirmed the facility's current census was 98 residents. The facility's Facility assessment dated [DATE] documents a Registered Nurse is needed every day in order to provide competent support and care for the facility's resident population.

Based on observation, interview and record review the facility failed to provide food that accommodates resident preferences and failed to provide appealing options to residents who choose not to eat food that is initially served. These failures have the potential to affect all 98 residents residing in the facility. Findings Include: R2's Medical Diagnoses List dated November 2025 documents R2 is diagnosed with Chronic Obstructive Pulmonary Disease, Lymphedema, Cellulitis, Congestive Heart Failure, Chronic Ulcers of the Feet, Bipolar Disorder, and Depression. R2's Minimum Diagnoses Sheet dated 10/6/25 documents R2 is cognitively intact. R2's Physician Order Sheet documents R2 is prescribed a no added salt, regular diet. R2's undated Dietary Card documents R2 dislikes fish, chicken, beets, or squash. The facility's Monthly Menus dated 11/23/25 documents chicken or fish will be served 13 times throughout the month. On 11/30/25 at 1:20 PM R2 stated he is tired of not having any food choices. R2 stated the facility provides no appealing alternatives for residents that do not choose 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 and record review, the facility failed to ensure the nursing staff consistently completed and signed controlled substance count sheets at the end of each shift. This failure has the potential to affect two of four residents (R1, R2) reviewed for controlled substance count sheets in the sample of four. Findings include:R1's Physician Order Sheet dated November 2025 documents an order for Hydrocodone- Acetaminophen (Opioid combination-controlled substance) 10-325 milligrams every four hours as needed for pain.R2's Physician Order Sheet dated November 2025 documents an order for Hydrocodone- Acetaminophen (Opioid combination-controlled substance) 5-325 milligrams for arthritis pain.Review of the facility's Shift Verification of Controlled Substances Count sheets dated August 2025, September 2025, October 2025, and November 2025, document numerous blanks where nurses did not sign off as performing the count for multiple shifts during these four months.On 11/28/25 at 10:00 AM, V4 (Licensed Practical Nurse/LPN) stated the count is done after very shift but V4 forgot 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 update a care plan to accurately include transfer/walking status and assistive devices for one of four residents (R2) reviewed for falls in the sample list of four. Findings include:On 10/14/25 at 12:33 PM R2 was lying in bed with her wheeled walker at the bedside. R2 stated R2 fell in the bathroom a few weeks ago by herself with no initial injuries, but the next day R2 was hurting really bad and found to have broken her tailbone. R2 stated now R2 has to use a wheeled walker and has been receiving therapy. R2 stated R2 transfers and walks independently without any staff assistance. R2's 9/22/25 Minimum Data Set (MDS) documents R2 as cognitively intact and R2 transfers/walks with staff supervision or touch assistance. R2's active care plan includes a problem dated as revised 7/26/24, which documents R2 needs staff supervision and/or assistance with activities of daily living and R2 does not use any assistive devices for walking. This care plan includes interventions dated 6/26/25 which document R2 walks…

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

Based on observation, interview, and record review, the facility failed to obtain physician orders for oxygen therapy (R4), failed to administer oxygen according to physician orders (R11), and failed to change oxygen humidifier bottles and tubing according to physician orders (R4 and R11). These failures affect two residents (R4 and R11) out of five reviewed for specialized services on a sample of eleven. Findings include: 1) R4's medical diagnoses list dated 9/24/25 documents R4 experiences medical conditions including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, Respiratory Conditions due to Unspecified External Agent, Chronic Congestive Heart Failure, and Unstable Chest Pain. On 9/23/25 at 10:04 AM, R4 was seated in a recliner in his room receiving oxygen therapy through a nasal cannula tubing from an oxygen concentrator running at two and one half liters per minute. R4's oxygen humidifier bottle was completely dry. R4's nasal cannula and humidifier bottle were dated 9/1 (2025). On 9/23/25 at 10:04 AM, R4 stated his oxygen should be running…

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 accurately record provided services by documenting incomplete treatments as completed. This failure affects two residents (R4 and R11) out of five reviewed for specialty services and treatments on the sample list of eleven. Findings include: 1) On 9/23/25 at 10:04 AM, R4 was seated in a recliner in his room receiving oxygen therapy through a nasal cannula tubing from an oxygen concentrator running at two and one half liters per minute. R4's oxygen humidifier bottle and nasal cannula tubing were both dated 9/1 (2025) to indicate the last time they were changed. R4's oxygen humidifier bottle was completely dry. R4's current Physician Order Sheet dated 9/24/25 documents R4's oxygen humidifier bottle and nasal cannula tubing need to be changed weekly on Sunday nights. R4's Treatment Administration Record for September, printed on 9/24/25, includes nursing staff initials and a checkmark on each of the scheduled dates when R4's oxygen humidifier bottle and nasal cannula tubing was scheduled to be changed, 9/7,…

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 dignity was provided during incontinence care and mealtime for five of five residents (R3, R4, R5, R6, R7) reviewed for dignity in a sample list of seven residents.Findings include:1.R3's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Osteoarthritis, Hypertension, Disorders of Bone Density and Structure, Cardiomyopathy, Dysphagia and Mild Protein-Calorie Malnutrition.R3's Brief Interview for Mental Status (BIMS) dated 8/22/25 documents R3 as severely cognitively impaired. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is fully dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. On 9/4/25 at 1:05 PM V9 and V12 (Certified Nursing Assistants/CNAs) provided incontinence care for R3. V9 and V12 pulled R3's sweatshirt up to R3's chest. V9 and V12 pulled down R3's pants to her knees. V9…

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 timely and complete incontinence care for one (R3) dependent resident out of three residents reviewed for incontinence care in a sample list of seven residents.Findings include: R3's Electronic Medical Record (EMR) documents medical diagnoses as Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Osteoarthritis, Hypertension, Disorders of Bone Density and Structure, Cardiomyopathy, Dysphagia and Mild Protein-Calorie Malnutrition.R3's Brief Interview for Mental Status (BIMS) dated 8/22/25 documents R3 as severely cognitively impaired. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is fully dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. On 9/4/25 at 1:00 PM V9 and V12 Certified Nursing Assistants/CNAs) provided incontinence care for R3. V9 and V12 did not provide a clean field for cleansing supplies. V9 placed a white bath towel on R3's 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 interview and record review the facility failed to notify one (R1) residents court appointed Guardian of changes in medications and laboratory orders out of three residents reviewed for notifications in a sample list of four residents. Findings Include:R1's Electronic Medical Record (EMR) documents R1's primary diagnosis is the medical management of Paranoid Schizophrenia. Other medical diagnoses include Thyrotoxicosis, Noncompliance with medication regimen, Cannabis abuse with Psychotic Disorder with Hallucinations, Major Depressive Disorder, Anxiety and Insomnia.R1's Letters of Office-Guardianship filed 11/18/2024 documents R1 as a 'Disabled Adult' and that V4 has been appointed R1's Court Appointed Guardian. This same letter documents V4 has access to the psychological healthcare providers and the psychiatric healthcare providers of R1, consent to the psychological and psychiatric treatment for the benefit of R1, consent to or withdraw the administration of psychological and psychiatric, psychotropic medications for the benefit of R1, consent to or refuse any treatment…

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 administer one (R1) resident's psychotropic medication per physician order causing R1 to miss ten doses. This failure affected one (R1) out of three residents reviewed in a sample list of four residents. Findings Include:R1's Electronic Medical Record (EMR) documents R1's primary diagnosis is the medical management of Paranoid Schizophrenia. Other medical diagnoses include Thyrotoxicosis, Noncompliance with medication regimen, Cannabis abuse with Psychotic Disorder with Hallucinations, Major Depressive Disorder, Anxiety and Insomnia.R1's Physician Order Set (POS) dated August 2025 documents a physician order starting 4/7/25 for Ativan 0.5 milligrams (mg) twice daily for Anxiety.R1's Pharmacy packing slip dated 6/8/25 documents 30 tablets of Ativan 0.5 milligrams (mg) were delivered to the facility on 6/8/25.R1's Medication Administration Record (MAR) dated June 2025 documents R1 was not administered her physician ordered Ativan 0.5 mg on the mornings of 6/7/25, 6/23/25 and on the evenings of 6/6/25, 6/7/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a clean, homelike environment in four of the facility's community shower rooms for two residents (R1, R2) out of three residents reviewed for physical environment in a sample list of three residents. Findings include: On 5/30/25 at 8:30 AM V5 (Licensed Practical Nurse/LPN) showed the east end shower on the back side of the building. This shower room had round vents in the ceiling that had a nickel thick layer of dust all around all the rings. The tile around the toilet area measuring three tiles deep by seven tiles wide were missing showing a rough, uneven floor. V5 LPN stated the staff giving showers open the window when it gets too humid in the shower room. This same shower room had a baseboard heater with the metal cover removed revealing the internal heating component. This baseboard heater was positioned inches away from the shower area. On 5/30/25 at 8:35 AM V4 (Housekeeper) stated the community shower rooms are sometimes a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report allegations of verbal and/or mental abuse to the Abuse Coordinator timely on three separate occasions involving R5 verbally and mentally abusing R4 on 4/22/25, R8 verbally abusing R7 on 4/6/25 and R9 verbally abusing R10 on 4/7/25. These failures affect six residents out of nine residents reviewed for abuse in a sample list of 12 residents. Findings include: 1. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R4 and R5's shared Initial Report to the State Agency dated 4/23/25 documents R5 allegedly verbally abused R4 on 4/22/25. On 4/23/25 at 1:45 PM V9 (Psychosocial Rehabilitation Director/PRSD) stated she was aware that R5 had yelled and screamed profanities and took a swing at R4 on 4/22/25 and did not report that behavior to anyone. V9 stated she was not aware that verbal and/or mental abuse needed to be reported as an allegation of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate Certified Nursing Assistant (CNA) staffing for eight out of 14 days reviewed for staffing. This failure has the potential to affect all 83 residents residing in the facility. Findings include: The facility Midnight Census Report dated 4/19/25 documents 83 residents reside in the facility. This same report documents 52 residents reside on the 500 and 600 halls. The Facility assessment dated [DATE] documents the facility should provide 16 CNAs per 24-hour period. The Daily 24-hour Staffing Assignment sheets document the total number of CNAs for each of the following days as: -4/5/25 document 14 CNAs -4/6/25 document 10 CNAs -4/12/25 document 11 CNAs -4/13/25 document 14 CNAs -4/14/25 document 13 CNAs -4/16/25 document 13 CNAs -4/17/25 document 12 CNAs -4/18/25 document 14 CNAs 1. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. This same MDS documents R2 requires the assistance of two staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a medication error rate under five percent for one (R3) resident out of four residents reviewed for medications in a sample list of seven residents. A medication administration pass was completed with three errors out of 28 opportunities resulting in a 10.7% medication error rate. Findings include: R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. R3's Physician Order Sheet (POS) dated April 2025 documents a physician order for Calgest (TUMS) 500 milligrams (mg) two chewable tablets twice a day, Gabapentin 300 mg three times a day, Levetiracetam 500 milligrams (mg) three tablets orally twice a day and Calcium 600 mg + (plus) D3 200 mg tablet daily. On 4/19/25 at 6:25 AM R3's Gabapentin medication card had a sticker that documents No Alum/Mag (Aluminum/Magnesium) Antacid within two hours. V8 (Licensed Practical Nurse/LPN) administered Calgest (TUMS) 500 mg two tablets and Gabapentin 300 mg together. V8…

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 there is a sufficient number of certified nursing assistants to provide care and respond to resident's basic individual needs. This failure has the potential to affect all 82 residents currently residing at facility. Findings include: Facility census dated 4/7/25 documents 82 residents in house, 29 residents on southwest hall (100's rooms), 23 residents on [NAME] East (500's rooms), and 30 residents on [NAME] (600's rooms). Facility assessment tool with documented updated date of 8/4/24 documents the facility has an average of 80-85 residents daily. Documents that capacity to manage oxygen therapy as well as CPAP and BIPAP, also documents on average the facility has 68 residents needed at minimum one person to 2 person assist, while about 20 are totally dependent on staff assistance for activities of daily living. 17 residents require assistance with ambulation while 45 residents are in some type of medical chair. More than half 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 there is a full time Director of Nursing (this was corrected during the survey). Facility also failed to ensure a Registered Nurse (RN) is providing services to residents at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 82 residents currently residing at facility. Findings include: Facility census dated 4/7/25 documents 82 residents in house, 29 residents on southwest hall (100's rooms), 23 residents on [NAME] East (500's rooms), and 30 residents on [NAME] (600's rooms). Facility assessment tool with documented updated date of 8/4/24 documents the facility has an average of 80-85 residents daily. Documents that capacity to manage oxygen therapy as well as CPAP and BIPAP, also documents on average the facility has 68 residents needed at minimum one person to 2 person assist, while about 20 are totally dependent on staff assistance for activities of daily living. 17 residents require assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and resident's representative of the transfer or discharge, including the reason, in writing to 4 (R1, R2, R4, and R5) residents out 4 reviewed for hospitalization in a sample size of 6. Findings include: Facility transfers and discharge policy, undated, documents the facility will not discharge a resident unless it is necessary to meet the resident's welfare. States the resident's attending physician must document in the residents' clinical record that the facility cannot meet the needs of the resident and that it would endanger the residents or others health. The facility must issue a 30-day notice of discharge to resident representative. 1.) R2's census dated [DATE] documents admission date of [DATE] with hospital leave on [DATE] and Stop [NAME] date of [DATE]. R2's face sheet dated [DATE] documents R2 has state appointed guardian. R2's Brief Interview for Mental Status dated [DATE] documents R2 is severely cognitively impaired.…

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 notify the resident and resident's representative at the time of transfer to hospital in writing of the bed-hold policy to 3 (R1, R2, and R4) residents out 3 reviewed for hospitalization in a sample size of 6. Findings include: Facility's Bed Hold Guarantee Policy dated [DATE] documents that after hospitalization a resident shall be guaranteed a bed in the facility upon return if the resident's condition is appropriate for the level of care facility provides, and that residents representative will be given a bed hold policy notice no later than 24 hours after time of transfer. 1.) R2's Brief Interview for Mental Status dated [DATE] documents R2 is severely cognitively impaired. R2's progress note dated [DATE] documents resident had complaints of coughing. Oxygen saturation levels low at 88-90%. Nurse practitioner and guardian notified. 911 called, report called to hospital. There is no documentation in R2's medical record that a written notice of bed…

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 safe transfer and thoroughly investigate a fall to identify root cause for one (R1) of three residents reviewed for falls in the sample list of six. Findings include: The facility's Fall Prevention policy dated 11/10/18 documents a fall huddle will be conducted with staff on duty immediately following a fall to help identify circumstances of the even and appropriate interventions, and circumstances of the fall will be documented in the nursing notes or on an Assess Intervene and Monitor for Wellness form. The facility's undated Transfer from Bed to Chair, Commode, or Wheelchair policy documents to use a gait belt and use a rocking technique to stand the resident. R1's Minimum Data Set, dated [DATE] documents R1 has moderate cognitive impairment and requires substantial/maximal staff assistance when moving from sitting to standing. R1's Care Plan dated 7/8/24 documents R1 has behaviors related to falls including being resistive to staff…

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 appropriate prescribing of antibiotics for one (R4) of four residents reviewed for urinary tract infections (UTIs) in the sample list of six. Findings include: The (official name of publisher) Educational Module for Nurses in Long-term care Facilities: Antibiotic Use and Antibiotic Resistance dated December 2014, provided by the facility on 4/8/25 as their policy, documents an example of antibiotic misuse as using broad-spectrum antibiotics when laboratory results indicate that a narrow-spectrum antibiotic would be effective. The facility's Resident Infection Control and Antimicrobial Log dated March 2025 documents R4 was prescribed Bactrim Double Strength (DS) 800-160 milligrams twice daily for 10 days from 2/27/25 through 3/9/25. This log documents microbiology results as mixed flora and criteria not met for clinical documentation to support antibiotic use and prescribing antibiotics for bacteria in the urine without the presence of clinical…

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 that a current copy of one (R3) resident's advance directive of three reviewed was accessible and in the resident's medical record during a medical emergency resulting in the facility staff delaying cardiopulmonary resuscitation. Findings include: The facility provided Advance Directive Policy dated 9/27/17 documents that any decision regarding advanced directives shall be indicated in the chart in the manner easily understood by all staff. Code staff shall be recorded on the resident's physician order sheet. The implementation of a code includes the review of the chart to determine code status. R3's progress notes dated 2/6/25 document that R3 was admitted to the facility. On 2/18/25, R3's electronic medical record does not document R3's code status, nor is there a physician order indicating code status. R3's Minimum Data Set, dated [DATE] documents R3 is severely cognitively impaired and primarily non-verbal. R3's progress notes dated 2/16/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all nursing personnel were certified in cardiopulmonary resuscitation. This failure has the potential to affect all 86 residents who currently reside in the facility. Findings include: The facility census documents a census dated [DATE] documents a census of 86 residents. The facility provided Cardiopulmonary Resuscitation Policy dated [DATE] documents that nursing personnel of this facility shall be certified in cardiopulmonary resuscitation (CPR) within a reasonable time after hire but not to exceed 90 days. On [DATE] at 3:30PM, V2 (Registered Nurse) stated that they were working on a plan to have all staff CPR certified soon. On [DATE] at 11:46AM, V18 (Regional Clinical Nurse) provided some staff CPR cards but that they could not produce a CPR card for all nursing personnel of the facility.

Based on observation, interview, and record review the facility failed to employ a full time Director of Nurses (DON). This failure has the potential to affect all 83 residents residing in the facility. Findings include: The facility Daily Midnight Census Report dated 1/21/25 documents 83 residents reside in the facility. The Facility assessment dated 8/2017 documents the facility will employ a full time Registered Nurse (RN) to be the DON. On 1/21/25-1/24/25 at various times during first and second shifts there was no DON onsite during survey timeframe. On 1/21/25 at 10:00 AM V1 (Administrator) stated the facility does not have a Director of Nurses (DON). V1 stated the facility has not had a DON for a few months and is currently looking to fill that position but have no prospects.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to report injuries of unknown origin to the State Agency for one (R22) out of one resident reviewed for abuse in a sample list of 33 residents. Findings include: R22's undated Face Sheet documents medical diagnoses of Cerebral Palsy, Mild Intellectual Disabilities, Schizoaffective Disorder, Bilateral Hearing Loss, Legal Blindness, Need for Assistance with Personal Care, Muscle Weakness and Dysphagia. R22's Minimum Data Set (MDS) dated [DATE] documents R22 as severely cognitively impaired. This same MDS documents R22 is dependent on staff for toileting, oral hygiene, personal hygiene and requires maximum assistance for bathing and transfers. R22's Care plan intervention dated 10/17/23 instructs staff to follow facility protocols for treatment of injury. This same care plan documents an intervention dated 2/23/24 that instructs staff to monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes.…

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 obtain a level II PASARR (Preadmission Screening and Record Review) for one resident (R31) of four residents reviewed for PASARR screenings identified as not having a diagnosis of serious mental Illness by the Level I PASARR but later was diagnosed with a serious mental illness in a sample of 33. Findings Include: R31's Care Plan dated 12/17/24 includes the following diagnoses: Psychotic Disorder, Cerebral Infarction with Dominant Right sided Hemiparesis/Hemiplegia, Anxiety, Major Depression, Dysphagia, Muscle Weakness, and Reduced Mobility. R31's Level I PASARR obtained prior to R31's admission on [DATE] documents no under the category History of Severe Mental Illness. However, the diagnoses Psychotic Disorder with Hallucinations was added to R31's diagnoses list on 7/24/21. The facility did not provide documentation a Level II PASARR was obtained. On 1/24/25 at 10:00 AM V14 (Admissions and Marketing Coordinator) stated We do not have a Level II PASARR…

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 obtain a level II PASARR (Preadmission Screening and Record Review) for one resident (R3) of four residents reviewed for PASARR screenings identified as having a diagnosis of serious mental Illness by the Level I PASARR in a sample of 33. Findings Include: R3's Care Plan reviewed 11/13/24 include the following diagnoses: Schizophrenia, History of Traumatic Brain Injury, and Major Depression. R3's Level I PASARR obtained prior to R3's admission on [DATE] documents yes under the category History of Severe Mental Illness. The facility did not provide documentation a Level II PASARR was obtained. On 1/24/25 at 10:00 AM V14 (Admissions and Marketing Coordinator) stated We do not have a Level II PASARR for (R3). I have arranged to have one completed as soon as the screener is available. On 1/24/25 at 10:30AM V1 (Administrator) verified (V14) is the staff member accountable for PASARR screenings. V1 indicated the facility does not have a specific policy 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent cross contamination during wound treatment and failed to assess, monitor, obtain treatment orders and implement care plan interventions for pressure sores for one (R75) of three residents reviewed for pressure sore in a sample list of 33 residents. Findings include: R75's undated Face Sheet documents R75 admitted to the facility on [DATE]. This same face sheet documents R75's medical diagnoses as Right Femur Fracture (12/24), Aneurysm of Heart, Chronic Congestive Heart Failure, Atrial Fibrillation, Chronic Kidney Disease, Morbid Obesity, Right Buttock Pressure Ulcer Stage II, Diabetes Mellitus Type II, and Dysuria. R75's Minimum Data Set (MDS) dated [DATE] documents R75 as cognitively intact. This same MDS documents R75 is dependent on staff for assistance with toileting and transfers and requires maximum assistance from staff for bathing, dressing and personal hygiene. R75's Shower/Abnormal Skin Report dated 1/16/25 documents…

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 prevent cross contamination during incontinence care. The facility also failed to maintain a urinary catheter drainage bag off the floor and in a dignity bag for two of three residents (R54, R1) residents reviewed for incontinence care and urinary catheters in a sample list of 33 residents. Findings include: 1. R54's undated Face Sheet documents medical diagnoses as Dementia, Psychosis, Sensorineural Hearing Loss, Dependence on wheelchair, unsteady on feet and Dysphagia. R54's Minimum Data Set (MDS) dated [DATE] documents R54 as severely cognitively impaired. This same MDS documents R54 is dependent on staff for toileting, transfers, and maximum assistance for bathing, dressing and personal hygiene. On 1/22/25 at 1:15 PM V6 and V7 (Certified Nurse Assistants/CNAs) completed incontinence care for R54. V6 and V7 both applied disposable gloves when removing R54's clothing and soiled incontinence brief. V6 and V7 both provided direct perineal…

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 identify/track resident specific targeted behaviors and failed to initiate resident centered interventions for one resident (R31) of five residents reviewed for Psychotropic medications in a sample list of 33. Findings Include: R31's Care Plan dated 12/17/24 includes the following diagnoses: Psychotic Disorder, Cerebral Infarction with Dominant Right sided Hemiparesis/Hemiplegia, Anxiety, Major Depression. Dysphagia, Muscle Weakness, Reduced Mobility. R31's Medication Administration Record for January 1, 2025 thru January 31, 2025 includes the following current physician's orders for psychotropic medications: 1. Lorazepam (antianxiety) Oral Concentrate 2 MG/ML Give 0.25 ml by mouth every 4 hours as needed for anxiety. 2. Seroquel (antipsychotic) Oral Tablet 25 MG Give 1 tablet by mouth in the morning for Anxiety/Agitation. Seroquel Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for agitation 3. Trazodone HCl (antidepressant) Oral Tablet 50 MG Give 0.5 tablet by mouth at bedtime 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to employ a full-time Director of Nurses (DON) and failed to have Registered Nurse (RN) coverage eight consecutive hours per day seven days a week for four of 14 days in a two week period. These failures have the potential to affect all 86 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (12/27/24- 01/02/25) there was no Director of Nurses working in the facility. On 12/27/24 at 1:10 PM V2 (Registered Nurse) stated the facility has not employed a full time Director of Nurse for months. On 12/27/24 at 3:20 PM V1 (Administrator) confirmed the facility has not employed a Director of Nursing for several months. On 01/02/25 at 11:40 am V24 (Nurse Scheduler/ Human Resources) confirmed the schedule for the past two weeks. V24 stated the following: (V2 RN) does not work the floor. Though the nursing schedule has her on it. She comes in part-time and does background office work. (V25 RN) is our only RN. 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 protect a resident's right to be free from physical abuse by another resident. This failure affects one of four residents (R2) reviewed for abuse on the sample list of 14. Findings include: R1's Current Diagnoses Sheet includes the following: Schizophrenia, Unspecified, and Major Depressive Disorder Recurrent. R1's Brief Interview of Mental Status Evaluation dated 11/13/24 documents R1's score as five out of a possible 15, indicating severe cognitive impairment. R1's Care Plan dated 11/08/24 documents the following: Focus: Behavior: Verbal/physical: Resident has behaviors that others may find disruptive/socially inappropriate. Others may seek reprisal against this Resident. Behavior exhibited Verbal aggression. Physical aggression. The same Care plan documents Intervention: Intervene as needed as soon as behavior is noted to ensure safety of residents and others. R1's Health Status Note dated 12/15/24 at 9:06 am documents the following: Resident (R1)…

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 dependent resident assistance with dressing and hygiene needs. This failure affects one of three residents (R4) reviewed for assistance with activities of daily living on the sample list of 14. Findings include: R4's current Diagnoses sheet documents the following: Morbid Obesity, Severe (80-100 pounds over the desired body weight) Due to Excessive Calories, and Diabetes Mellitus Type II with Diabetic Autonomic (Poly) Neuropathy (nerve damage that causes pain, numbness, tingling, swelling and weakness in different parts of the body) R4's Minimum Data Set (MDS) dated [DATE] documents R4 has a Brief Interview of Mental Status score of 12 out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R4 requires Supervision and touching assistance to meet his hygiene needs. R4's Care Plan dated 12/05/24 documents the following: Focus: Incontinent: Check q (every) 2 (two) hours and as required 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete skin assessments after skin impairment was identified (12/09/24), failed to measure new skin impairment, failed to obtain wound treatment orders in a timely manner, and failed to obtain a physician order prior to applying medication to a resident's skin impairment. These failures affect one of four (R4) residents reviewed for skin impairment/treatments on the sample list of 14. Findings include: R4's current Diagnoses sheet documents the following: Morbid Obesity, Severe (80-100 pounds over the desired body weight) Due to Excessive Calories, and Diabetes Mellitus Type II (DMII) with Diabetic Autonomic (Poly) Neuropathy. R4's Minimum Data Set (MDS) dated [DATE] documents R4 has a Brief Interview of Mental Status score of 12 out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R4 requires supervision and touching assistance with hygiene needs and has occasional incontinent with urine. R4's Care Plan…

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 a skin assessment with measurements and accurate description, obtain a pressure ulcer treatment order in a timely manner, and obtain a physician order before applying medication to a pressure ulcer. These failures affect one of four residents (R4) reviewed for skin impairment/treatments on the sample list of 14. Findings include: R4's current Diagnoses sheet documents the following: Morbid Obesity, Severe (80-100 pounds over the desired body weight) Due to Excessive Calories, and Diabetes Mellitus Type II (DMII) with Diabetic Autonomic (Poly) Neuropathy. R4's Minimum Data Set (MDS) dated [DATE] documents R4 has a Brief Interview of Mental Status score of 12 out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R4 requires supervision and touching assistance with hygiene needs and has occasional incontinent with urine. R4's Care Plan updated 12/05/24 documented areas included the following: Focus:…

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 timely incontinence care for one of three residents (R4) reviewed for incontinence care on the sample list of 14. Findings include: R4's Minimum Data Set (MDS) dated [DATE] documents R4 has a Brief Interview of Mental Status score of 12 out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R4 requires supervision and touching assistance with hygiene needs and has occasional incontinent with urine. R4's Care Plan updated 12/05/24 documents the following: Focus: Bladder Function: The resident has bladder incontinence which can cause impaired skin integrity and needs monitored. Brief Use: The resident uses disposable briefs. Change q (every) 2 (two) hours and prn (as needed), as resident requires. Incontinent: Check q 2 hours and as required for incontinence as resident requires. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Focus: Activities of Daily Living (ADLs):…

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 qualified licensed staff apply Nystatin (medication antifungal powder) for one of four residents (R4) reviewed for skin impairment/treatments on the sample list of 14. Findings include: On 12/27/24 at 2:33 PM R4 was seated in a recliner in his room. R4 stated I have a lot of discomfort sometimes from the rash I have on privates. Sometimes I don't feel any pain at all. The CNAs (Certified Nursing Assistants) sometimes put a cream on the rash, after my shower every week. That does feel better. I can't do the cream myself. I am too (overweight). I do the best I can, on my own, to go to the toilet. I can't stand very long because of the issues with my lower legs. On 12/27/24 at 2:50 PM V10 (CNA/Shower Aide) assisted R4 to the bathroom and provided incontinence care. R4's right groin, under leg crease had eight inches by five inches of red, raw skin with a patch of approximately one inch strip of yellow white pus-like drainage down the center. R4 had a large pannus that hung over and touched R4's groin area.…

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 a resident that was out of the facility at a doctor's appointment. This failure affects one of eight residents (R4) reviewed for complete/accurate medical records on the sample list of 14. Findings include: On 12/30/24 at 2:04 PM V32 (Registered Nurse/RN at the Vascular Clinic) stated R4 came to the Vascular Clinic for an appointment 12/09/24 at 7:00 am. V32 stated she called the facility and spoke to V15 (Agency Licensed Practical Nurse/LPN). V32 stated she informed the facility that R4 had arrived for his appointment unkept, saturated in urine and with skin impairment of R4's groin. V32 stated the facility was informed R4 had no treatment order for this skin impairment but will need a physician to order one. On 12/31/24 at 11:55 am V2 (RN) reviewed R4's chart. V2 confirmed there is no documentation to indicate R4 went out to an appointment to vascular center on 12/09/24. There is no documentation of R4's return, there is no documentation that R4 was soiled with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow its grievance policy by failing to complete a grievance form for one (R2) of five residents reviewed for abuse in the sample list of five. Findings include: The facility's Resident Grievances/Complaints dated 11/1/17 documents staff are required to report resident grievances/complaints to the Social Service Director (SSD) and these grievances/complaints are brought to the daily Quality Assurance meetings so the interdisciplinary team can determine the best resolution. This policy documents grievance/complaint investigations will be completed within five working days and the SSD will keep copies of the completed forms. This policy documents the SSD and Administrator will discuss the grievance/complaint with everyone involved, and the results of the investigation and interventions will be reported to the resident/resident representative and documented on the Grievance/Complaint Report Form. On 12/2/24 at 9:44 AM R2 stated there was only one time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to timely report an allegation of physical abuse to the state survey agency for one (R1) of five residents reviewed for abuse in the sample list of five. Findings include: The facility's Abuse Prevention Program dated February 2021 documents The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of a crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and (state survey agency) immediately after forming the suspicion (but not later than two hours after forming the suspicion). Otherwise, the report must be made…

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 sufficiently staff Certified Nursing Assistants during the night shift in order to provide services to meet the residents' needs in a manner that promotes each resident's rights and well-being. This failure affects four residents (R1, R2, R3, R4) of four reviewed for staffing in the sample list of four and has the potential to affect all 79 residents residing in the facility. Findings Include: The Facility Assessment Tool dated 8/2/24 documents the facility has an average daily census of 80-85 residents. The same tool documents on average the facility have around 35 residents who require one to two staff to assist them with toileting and around 16 residents that are completely dependent on staff for toileting. The same tool documents the facility requires the services of Certified Nursing Assistants (CNA) to provide competent support and care for their resident population on a daily basis. The same tool documents the facility has identified on average…

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 conduct pressure ulcer risk assessments according to the facility policy and failed to complete physician ordered weekly skin checks. This failure affects two residents (R1 and R3) out of three reviewed for pressure ulcers on a sample of three. Findings include: The facility policy Preventative Skin Care dated 3/16/23 documents, All residents will be assessed using the Braden Pressure Ulcer Scale at the time of admission and weekly x 4 then quarterly and/or as needed. 1. R1's Electronic Medical Record documents R1 was admitted to the facility 11/3/23. R1's Braden Scale Assessments were dated 1/1/24 and 6/13/24. R1's Braden Scale assessments for admission and the following four weekly assessments were absent from R1's medical record, as were any Braden Scale assessments between 1/1/24 and 6/13/24. 2. R3's Electronic Medical Record documents R3 was admitted to the facility 3/22/24. R3's Braden Scale Assessments were dated 4/12/24 (4th week after admission) and 5/15/24. R3's Braden Scale Assessments for admission and 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 interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of three residents (R1 and R2) reviewed for abuse in the sample list of seven. Findings include: R1's undated diagnoses list documents R1's diagnoses as: Alzheimer's Disease, unspecified; Dementia, unspecified severity, with other behavioral disturbance; Major Depressive Disorder, recurrent, moderate; unspecified Psychosis not due to substance or known physiological condition; and Schizophrenia, unspecified. R1's Minimum Data Set (MDS) dated [DATE], documents R1 is not cognitively intact. R2's undated diagnoses list documents R2's diagnoses as: Schizophrenia, unspecified; Major Depressive Disorder, recurrent, unspecified; and Undifferentiated Schizophrenia. R2's MDS dated [DATE], document R2 is not cognitively intact. This same MDS documents R2 has verbal behavior symptoms directed at others and rejects care. R2's Progress Notes dated 3/4/24 through 6/13/24,…

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 restraint and the least restrictive fall intervention was implemented. This failure affects one (R3) of three residents reviewed for restraints. Findings include: The facility Physical Restraint/Enabler Policy dated 7/24/18 documents that residents will be free of physical restraint which are not required to treat the resident's medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. A physical restraint is any manual method, or physical or mechanical device, equipment, or material attached or adjacent to the resident's body which the individual cannot remove easily and which restricts freedom of movement or normal access to his or her body. A device that may constitute a physical restraint may include bed rails, self-release waist restraints, soft waist restraints, lap top cushion, vest restraints, chair with tray table, arm…

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 investigate injuries of unknown origin for one (R1) of three residents reviewed for injuries of unknown origin from a total sample list of three. Findings include: The facility provided abuse policy dated 5/2021 documents that employees are required to immediately report any occurrences of potential/alleged mistreatment to a supervisor or the administrator. This includes the appearance of bruises, lacerations, or other injuries of unknown origin as they occur with subsequent investigation and review of documentation. Upon learning of the report, the administrator or designee shall initiate an investigation. R1's diagnoses include Urinary Tract Infections, Type II Diabetes Mellitus, Hemiplegia of the left, Hemiparesis of the left side, Delusional Disorder, Dysphasia, Schizophrenia with Bipolar Disorder and Seizures. R1's hospital readmission skin assessment dated [DATE] documents no bruising or alteration in skin integrity. R1's skin…

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 targeted interventions to prevent falls that resulted in injury in one (R2) of three residents reviewed for injuries. Findings include: The facility Fall Prevention Policy dated 11/10/18 documents that all staff must observe residents for safety. If residents with a high-risk code are observed up or getting up, help must be summoned, or assistance must be provided to the resident. After the fall, assessments and new interventions will be evaluated and put into place when appropriate. R2's undated diagnoses sheet includes Unspecified Dementia, Disorganized Schizophrenia, Generalized Anxiety Disorder, Depression, Psychotic Disorder with delusions due to a psychological condition, Chronic Heart Disease, Mild Intellectual Disability, Chronic Obstructive Pulmonary Disease, Convulsions, Asthma and Gastroesophageal Reflux Disease. R2's fall risk assessment dated [DATE] documents R2 as at risk for falls. R2's Minimum Data Set, 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 observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 88 residents in the facility. Findings include: On 3/12/2024 at 9:39AM, V7 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V7 reported being the full-time manager of the facility food service (person in charge) and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V7 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V7 reported the facility dietician only works in the facility one day per month. V7 also denied being a certified Food Protection Manager, as required, for every person in charge of a food service. V7 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality;…

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

Based on observation, interview, and record review, the facility failed to maintain sanitary food storage and service areas. These failures have the potential to affect all 88 residents in the facility. Findings include: On 3/12/2024 at 9:39AM, The kitchen walk-in cooler flooring was excessively soiled with accumulations of food debris, cardboard trash, single-serve condiment packets, and spilled liquids. Spilled food debris completely obscured part of the floor surface several square feet in size. Areas along the perimeter of the cooler floor surface appeared wet with accumulated food residues. An uncut and whole cucumber was located on a lower storage rack in an advanced state of decomposition, partially liquefied onto the floor below, and covered with a fuzzy gray colored substance resembling mold. Numerous single-serve condiment packets and cardboard scraps were imbedded into the matted and sticky food debris on the cooler floor. Wire food storage shelves in the cooler were soiled throughout with a fuzzy light gray colored substance resembling mold growth and the condenser fan…

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 follow its Legionella Policy and Procedure by failing to have the water system inspected annually and failed to have the boiler and thermostatic mixing valves serviced. This failure has the potential to affect all 88 residents residing in the facility. Findings include. The facility's Legionella risk assessment dated [DATE] documents answering yes to any of the following suggest a potential risk to being exposed to Legionella. This assessment documents yes to: Is facility a healthcare facility where patients stay overnight or does your facility house or treat people who have chronic and acute medical problems or weakened immune systems? This assessment documents that conditions are right for Bacteria to multiply, that there are areas where stagnant water could be stored, that there are infrequently used outlets in showers or taps, and that there is debris in the system such as rust, sludge, or scale that could provide food for the bacteria. 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 ensure the dignity of five residents (R1, R11, R27, R37, R64) out of five residents reviewed for dignity in a sample list of 41 residents. Findings include: The facility pamphlet titled 'Residents' Rights for People in Long-term Care Facilities' revised in May 1995 documents the facility must provide services to keep your physical and mental health, and sense of satisfaction. 1.) R64's Minimum Data Set (MDS) dated [DATE] documents R64 as severely cognitively impaired. This same MDS documents R64 as requiring maximum assistance with personal hygiene, dressing, bed mobility and transfers. On 3/13/24 at 1:10 PM V12 (Registered Nurse/RN) completed R64's Right Buttock Stage II Pressure Ulcer. V12 removed R64's pants to expose R64's entire buttocks. R64 did not have a privacy curtain. R64's roommate was lying in bed facing R64 with eyes open the entire time R64's buttocks were exposed. V12 did not provide privacy for R64 during wound care. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to promote the right to a safe, clean, comfortable homelike environment for 30 (R59, R37, R45, R51, R11, R43, R80, R73, R19, R1, R30, R56, R62, R28, R32, R61, R27, R10, R82, R77, R78, R79, R47, R24, R83, R75, R89, R87, R64, R66) of 88 residents reviewed for environment on the sample list of 41. Findings include: 1. On 3/12/23 at 9:00 AM and on 3/13/24 at 10:15 AM the dining room floor in which R59, R37, R45, R51, R11, R43, R80, R73, and R19 eat their meals had accumulated dirt and debris along the edges of the room. The floor had missing and cracked tile and had multiple stained areas. All the walls in the dining room were covered with scuff marks on the lower half of the walls. On 3/13/24 at 2:30 PM, V19 (Maintenance Director) stated that the walls in the dining room need painted and it is on a list of things to do. V19 stated he is the only Maintenance person in the building. V19 stated V40 (Floor Care Janitor) does the floors usually but…

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 the resident's right to be free from verbal abuse by a staff member for four residents (R75, R78, R79, R89) out of five residents reviewed for abuse in a sample list of 41 residents. Findings include: 1.) R75's Minimum Data Set (MDS) dated [DATE] documents R75 as cognitively intact. R75's Smoking assessment dated [DATE] documents R75 requires supervision with smoking. R75's Care Plan initiated 7/7/2023 does not include a focus area for R75 being at risk of abuse. On 3/15/24 at 9:30 AM R75 stated V37 (Licensed Practical Nurse/LPN) does not allow R75 to smoke at the designated smoking times. R75 stated A few weeks ago (R75) would not let several of us smokers out to smoke. (V37) told us that we could not go out because she didn't have time to take us. (V37) did not get anybody else. By the time the second smoke break came around I had waited over 14 hours from my last smoke. We were complaining about it outside and (V37) overheard us. When I got…

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 for one (R27) resident and failed to report an allegation of verbal abuse by a staff member for four residents (R75, R78, R79, R89). These failures affect five residents out of five residents reviewed for abuse in a sample list of 41 residents. Findings include: 1.) R27's undated Face Sheet documents medical diagnoses of Cerebral Palsy, Mild Intellectual Disabilities, Psychosis, Bilateral Hearing Loss, Legal Blindness, Lack of Coordination, Seizures, Need for Assistance for Personal Care and Right Ischium Stage 3 Pressure Ulcer. R27's Minimum Data Set (MDS) dated [DATE] documents R27 as severely cognitively impaired. R27's Assessment, Intercommunicate, Manage (AIM) report dated 3/9/24 documents R27 was observed to have an injury of unknown origin first noted on 3/9/24 at 10:00 PM. This same report documents R27 had a new skin tear to back of head measuring 0.2 centimeters (cm) by 0.5 cm by no depth documented. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a Continuous Positive Airway Pressure (C-PAP) was applied, ensure the C-PAP mask fit, and ensure respiratory equipment was dated, changed, clean, and kept off the floor to prevent contamination for four (R59, R10, R73, and R62) of four residents reviewed for respiratory on the sample list of 41. Findings include: 1. On 3/12/24 at 10:13 AM, R62 was lying in bed. An oxygen concentrator was sitting to the side of his bed. The oxygen tubing connected to the concentrator was labeled 12/23/23. R62 stated he uses the oxygen when he needs it. R62 stated he has a CPAP that he can't use because the mask doesn't fit. R62 stated the nursing staff don't come in and try to put it on him anymore. R62 stated the air blows out around his face. R62 states he can't wear it because it doesn't fit. R62 stated he would wear it if it fit. R62's quarterly Minimum Data Set assessment dated [DATE] documents R62 is cognitively intact. R62's care plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide skilled rehabilitation services to residents with physician orders to receive such services. This failure affects five residents (R15, R31, R34, R39, and R90) out of six residents reviewed for therapy services on the sample list of 41. Findings include: On 3/12/24 at 9:15 AM through 3/15/24 at 3:00 PM, there were no therapy providers nor personnel observed in the facility. On 3/14/24 at 9:47 AM, V1 (Administrator) stated, Our therapy company gave us a 5 day notice they were going to stop coming in to do therapy. The therapy company's last day working here was 2/20/24. We do have a report that a new therapy company has signed a contract, but I am not sure when the new company is supposed to start. The former therapy company did give the notice they were stopping their services because of non-payment for their services that comes from the corporate level. 1. R15's Physician Order Sheet dated for February 2024 documents R15 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.

Based on observation and interview the facility failed to ensure that bathroom call light cords were attached to the call light pull station and were able to be reached from the floor for six (R62, R43, R30, R55, R59, and R56) of 24 residents reviewed for call lights on the sample list of 41. Findings include: On 3/12/24 at 10:13 AM and on 3/13/24 at 10:00 AM, a call light cord was not attached to the call light pull station in R62 and R43's bathroom. On 3/12/24 at 11:26 AM and on 3/13/24 at 10:10 AM, the call light cord did not extend past the call light pull station in R30, R56, R55, and R59's bathroom. This cord would not be in reach if lying on the floor. On 3/13/24 at 2:30 PM, V19 (Maintenance Director) confirmed the call cord in R62 and R43's bathroom was not long enough to be reached if lying on the floor. At 2:40 PM, V19 confirmed that the call cord in R30, R56, R55, and R59's bathroom was missing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed ensure resident rights were maintained by failing to include a resident's family representative in R83's care plan conference. This failure affected one of one resident (R83) reviewed for care plan attendance/resident rights on the sample list of 41. Findings include: R83's Care Plan is documented as revised 02/28/24. R83's Minimum Data Set (MDS) dated [DATE] documents R83 Brief Interview of Mental Status score as three out of a possible 15, indicating severe cognitive impairment. The same MDS documents R83's initial admission to the facility as 10/17/23. On 03/12/24 at 11:27 am, V3 (R83's Family Representative/Power of Attorney) stated the following: (R83) is on Hospice (end of life care) now, as of last week. I have never been to a care plan conference since she (R83) has been here (admitted [DATE]). I talked to (V6 Social Service Director/SSD) in Social Service last week. There are several things I wanted to talk about for (R83). V6 said there will not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to document ongoing generally accepted accounting principles to account for residents' personal funds, failed to provide a quarterly financial report to a resident (R62) and a resident (R83) family representative. These failures affected two of two residents (R62 and R83) reviewed for resident funds on the sample list of 41. Findings include: 1. On 03/12/24 at 11:24 am during a family interview, V3 stated I am (R83's) POA (Power of Attorney) and Guardian. I bring in (R83's) pension checks every month. Her (R83's) Social Security checks come directly to the facility. I have never received a financial statement from the facility. (R83) has been here since 10/17/23. On 3/12/24 at 3:25 pm V8 (Business Office Manager/BOM) stated (R83) has not received a quarterly statement of funds. Our (the facility) electronic system for finances went down in October (2023). We now have to hand write the statements. I am really behind since I have to handwrite 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 interview and record review, the facility failed to complete Minimum Data Sets (MDS) Resident Assessment Instrument (RAI) in the required time frame, failed to complete Care Area Assessments (CAAs) in the required time frame, and failed to complete care planning processes in the required time frame. This failure affects three residents (R12, R19, and R80) out of three reviewed for MDS completion on the sample list of 41. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long Term Care Resident Assessment Instrument 3.0 User's Manual dated October 2023 documents a comprehensive MDS (Annual, Admission, and Significant change) is required to be completed, including the CAAs, within 14 days of the ARD. This manual document the care planning process is required to be completed 7 days after the CAA completion. This same manual document a quarterly MDS is required to be completed within 14 days after the ARD. 1. R12's comprehensive (Annual) MDS dated with an Assessment Reference Date (ARD) of 2/1/24 documented a completion date, including the CAAs, of 3/5/24.…

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 prevent cross contamination and follow wound treatment order during pressure ulcer wound care for one (R64) out of two residents reviewed for pressure ulcers in a sample list of 41 residents. Findings include: R64's undated Face Sheet documents R64 admitted to facility on 9/19/2017 with medical diagnoses of Dementia, Bipolar, Anxiety, Diabetes Mellitus Type II, Repeated Falls, Need for Assistance with Personal Care and Right Buttock Stage 3 Pressure Ulcer. R64's Minimum Data Set (MDS) dated [DATE] documents R64 as severely cognitively impaired. This same MDS documents R64 as requiring maximum assistance with personal hygiene, dressing, bed mobility and transfers. R64's Pressure Ulcer Risk assessment dated [DATE] documents R64 as being at risk for obtaining pressure ulcers. R64's Wound Evaluation and Management Summary dated 3/7/24 documents a physician order to cleanse right buttock pressure area with soap and water or wound cleanser. Apply…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement fall interventions for one (R64) resident resulting in a fall with injury out of eight residents reviewed for Accidents in a sample list of 41 residents. Findings include: R64's undated Face Sheet documents R64 admitted to facility on 9/19/2017 with medical diagnoses of Dementia, Bipolar, Anxiety, Diabetes Mellitus Type II, Repeated Falls, Need for Assistance with Personal Care and Right Buttock Stage 3 Pressure Ulcer. R64's Minimum Data Set (MDS) dated [DATE] documents R64 as severely cognitively impaired. This same MDS documents R64 as requiring maximum assistance with personal hygiene, dressing, bed mobility and transfers. R64's Physician Order Sheet (POS) dated March 2024 documents a physician order starting 11/15/2023 to use bed/chair alarm due to unaware of safety needs related to dementia. Check battery every shift. R64's care plan does not include a focus area, goal nor intervention related to R64's documented fall risk. R64's Fall…

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 catheter collection bags and tubing were positioned up off the floor to prevent contamination for three (R1, R37, and R31) of four residents reviewed for catheters on the sample list of 41. Findings include: 1. On 3/12/24 at 9:50 AM, R1 was sitting in a recliner in his room. R1's catheter collection bag was lying directly on the floor. The bag was uncovered, and the entire side of the bag and port was touching the floor. On 3/13/24 at 8:45 AM, R1's was sitting in a recliner in his room. R1's catheter collection bag was lying directly on the floor. The bag was uncovered, and the entire side of the bag and port was touching the floor. R1's catheter care plan dated 1/12/24 documents R1 has a diagnosis of Neurogenic bladder and Urethral Stricture and requires an indwelling catheter. This care plan documents R1 has a history of recurrent urinary tract infections. 2. On 3/12/24 at 8:46 AM, R37 was lying in bed. R37's catheter collection…

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 recommendations made by the Registered Pharmacist. This failure affects one resident (R87) out of five reviewed for unnecessary medications on the sample list of 41. Findings include: R87's Pharmacy Consultation Report dated 8/1/23 through 8/15/23 documents a Registered Pharmacist recommendation to adjust the administration time for R87's medication Latuda in order to ensure proper absorption. This same report has a hand-written note Note in place to give with food. R87's current Physician Order Sheet dated for March 2024 does not include a note for R87's medication Latuda to be given with food. R87's Medication Administration Record dated for March 2024 does not include any administration detail to give with food. On 3/14/24 at 1:50 PM, V2 (Director of Nursing) stated, I don't know about that hand-written note because I didn't write that, that was before I started working here. I would have put a note in the physician order details so it would show up on the Physician Orders and The MAR (Medication…

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 pharmacy instruction for the administration of medication, in accordance with facility policy and pharmacy protocol, for 2 of 8 residents (R75 and R78) reviewed during medication observation. The facility had 2 medication errors out of 25 opportunities resulting in an 8 percent medication error rate. Findings include: 1. R78's Physician Order Sheet dated 3/15/24 documents the following: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) micrograms per actuation take two puffs inhale orally four times a day. Diagnosis Chronic Obstructive Pulmonary Disease with Acute Exacerbation. On 3/13/24 at 11:10 am V12 (Registered Nurse/RN) handed R78's an Albuterol Sulfate Inhalation Aerosol 108/mcg cartridge and instructed R78 to 'take two puffs'. V12 gave no further direction. R78 inhaled two puffs rapid succession with no delay between inhalation of the respiratory medication. R78's Albuterol Sulfate Inhalation Aerosol 108/mcg cartridge pharmacy label directs the administration process 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 label a resident's eye drop bottle with the resident's name, and the date the bottle was opened. This failure affected one of eight residents (R78) reviewed during medication administration on the sample list of 41. Findings include: R78's Physician Order Sheet dated 3/14/24 documents the following: Artificial Tears Ophthalmic Solution (Artificial Tear Solution), Instill two drops in both eyes every four hours for Dry Eyes, may keep at bedside. On 3/13/24 at 11:10 am V12 (Registered Nurse) administered R78's Artificial Tears Ophthalmic Solution, two drops into each of R78's eyes. There was no name or date when the bottle was opened for the Artificial Tears Ophthalmic Solution bottle. V12 confirmed there is no date or name on the bottle of eye drops. On 3/15/24 at 9:20 am V2 (Director of Nursing) stated her expectation is for nurses to date and label the resident's name on eye drop bottles when opened to ensure accuracy of the appropriate time to discard. The facility policy Procurement and Storage of Medication…

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

Based on observation, interview, and record review the facility failed to ensure a bed rail was affixed firmly to the bed frame for two of two (R1, R62) residents reviewed for bed rails on the sample list of 41. Findings include: 1. On 3/12/24 at 11:20 AM, a full-sized bed rail was attached to the left-hand side of R1's bed. This rail moved back and forth very easily when moved. This rail was not secure. On 3/13/24 at 2:30 PM, V19 (Maintenance Director) shook R1's bed rail and stated that it could be tightened. V19 stated that it will not tighten so that it is secure due to the type of rail it is. V19 stated it is an old bed. 2. On 3/12/24 at 11:26 AM, R62's bed had one quarter side rails on both sides of his bed. The bed rails moved easily back and forth and were not secured to the bed. On 3/13/24 at 2:35 PM, V19 stated that the rails were a little loose. The facility did not provide a schedule for regular maintenance of residents' bedrails/bedframes.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the resident's (R2, R3) rights to be free from physical abuse by another resident (R1). This failure affects three (R1, R2 and R3) of three residents reviewed for abuse in the sample of three. Findings include: 1. R1's Diagnosis Sheet (current) includes the following diagnoses: Major Depression, General Anxiety, Alcohol Abuse and Paranoid Schizophrenia. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as being cognitively intact. This same MDS documents R1 with behaviors of aggression toward others. R1's Care Plan (current) documents R1 as being aggressive towards staff and residents. R3's Diagnosis Sheet (current) includes the following diagnoses: Hemiplegia, Hemiparesis, Major Depression, Anxiety and Paranoid Schizophrenia. R3's MDS dated [DATE] documents R3 as being moderately cognitively impaired. This same MDS documents R3 as having no behaviors during the assessment period. A facility report titled Final Report dated 1/15/24…

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 their Abuse Prohibition Policy by not thoroughly investigation allegations of resident abuse. This failure affects two (R1, R3) of three residents reviewed for abuse allegations in the sample of three. Findings include: A facility report titled Initial Report dated 1/9/24 documents a resident-to-resident physical altercation and was reported to the State Agency on 1/9/24 at 11:21 am, per confirmation email from the State Agency to the facility. A facility report titled Final Report dated 1/15/24 documents the following incident and subsequent investigation: On 1/9/24 (R3) was propelling (R3's) chair backwards and accidentally ran into (R1). This startled (R1) and (R1) started hitting (R3) and then in return (R3) swung back. There was some contact, but no injuries were noted. They were both assessed by the nurse after they were separated by the staff. Included in the above report and investigation, V1 (Administrator) documents the following on a facility Witness Statement: Date of Incident: 1/8/24, Time 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 physical abuse between two residents (R1, R3) in an appropriate time frame. R1 and R3 are two of three residents reviewed for abuse in the sample of three. Findings include: A facility report titled Final Report dated 1/15/24 documents the following incident: On 1/9/24 (R3) was propelling (R3's) chair backwards and accidentally ran into (R1). This startled (R1) and (R1) started hitting (R3) and then in return (R3) swung back. There was some contact, but no injuries were noted. They were both assessed by the nurse after they were separated by the staff. The initial reporting of the above incident was reported on 1/9/24 at 11:21 am per confirmation email from the State Agency to the facility. Included in the above report and investigation, V1 (Administrator) documents the following on a facility Witness Statement: Date of Incident: 1/08/24, Time of Incident: 4:30 pm: I was notified by (V4 Registered Nurse) on 1/8/24 at 4:30 pm and was told that (R3) was moving (R3's) wc (wheelchair) backward and…

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

Based on interview and record review, the facility failed to provide the services of a Registered Nurse for 8 consecutive hours, 7 days per week. This failure has the potential to affect all 92 residents residing in the facility. Findings include: The facility's historical Nurse Schedule dated from 1/17/24 through 2/1/24, documented no Registered Nurses (RNs) worked on the days of 1/20/24 and 1/21/24. These days were documented with blanks for all the RNs listed on the schedule with the exception that there was one RN scheduled to work both of these dates, but the space for that RN was coded with CI. On 2/2/24 at 1:45 PM, V21 (Nurse Scheduler) stated, The 'CI' means that person called in, so they didn't work their shift. On 2/2/24 at 2:28 PM, V1 (Administrator) looked through the computer payroll records and stated, It looks like (V17 former Director of Nursing) worked from 6:00 PM on the 19th (1/19/24) until 6:00 AM on the 20th (1/20/24). V1 further stated, And (V10 Registered Nurse) worked from 10:00 PM on the 21st (1/21/24) until 6:00 AM on the 22nd (1/22/24). V1 concluded,…

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 homelike, clean, and comfortable environment related to sewage backflow issues rendering showers and toilets inoperable, interruptions in hot water supply, and intermittent inadequate heating. This failure affects 15 residents (R1, R2, R10, R11, and R17 through R27) out of 15 reviewed for physical plant problems on the sample of 27. Findings include: On 2/1/24 at 12:14 PM, V19 (Former Human Resources Representative) stated, I went down on the covid unit (400 hall) back in October (2023) to get some files and the sewer smell back there was noxious. That was well before they ever put any residents down there. After being in there 5 minutes, I thought I was going to get sick and pass out. V19 further stated, I haven't been back down there since then, but I had a lot of other employees coming to me after they put residents down there and telling me it hadn't gotten any better and the showers and toilets weren't working. On 2/1/24 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 observation, interview, and record review, the facility failed to maintain a medication cart in a locked or supervised condition, allowing potential access to an independently mobile cognitively impaired resident in the direct vicinity to the medication cart on the covid-19 isolation unit. This failure affects one resident (R20) out of three reviewed for mobility and cognitive status residing on the covid isolation unit, on the total sample of 27. Findings include: On 2/1/24 at 1:58 PM, V3 (Licensed Practical Nurse/LPN) working on the covid-19 isolation unit, stated to V14 (Certified Nursing Assistant/CNA), I need to go give report on the other hall. On 2/1/24 at 2:03 PM, the medication cart was noted to be unlocked with the locking button obviously protruding from the front of the cart. V3 (LPN) had left the covid isolation unit, leaving only V14 (CNA) the only employee present on the unit. R20 was approximately 8 feet away from the medication cart directly across the hall. R20'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.

Based on observation, interview and record review the facility failed to prevent the misappropriation of resident smoking materials/funds. This failure affects nine of twelve residents (R6, R8, R9, R10, R11, R12, R14, R15 and R16) reviewed for smoking on the sample list of 18. Findings include: The facility abuse policy dated 2/2021 documents that misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belonging or money without the resident's consent. Eyewitness accounts indicate that there was suspicious activity surrounding the item or the area that might indicated possible theft, regardless of the value of the property. The facility report to the state agency documents that on 12/22/2023, V5 (previous Psychiatric Rehabilitation Service Coordinator/PRSC) reported to V1 (Administrator) that the practice on the mental health unit for managing cigarettes, was to buy cigarettes with money from those who had it, including those who did not pay for the cigarettes, and then place them into a communal…

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 follow their abuse policy to report allegations of misappropriation of resident smoking materials/funds to resident families for nine of twelve residents (R6, R8, R9, R10, R11, R12, R14, R15 and R16) reviewed for misappropriation on the sample list of 18 residents. Findings include: The facility Abuse Policy dated 2/2021 documents in the External Reporting of Potential Abuse, that the administrator or designee will report the potential abuse to the resident's representative, that an investigation is taking place and the results of that investigation. The facility report to the state agency documents that on 12/22/2023, V5 (Psychiatric Rehabilitation Service Coordinator/PRSC) reported to V1 (Administrator) that the practice on the mental health unit for managing cigarettes, was to buy cigarettes with money from those who had it (R6, R8, R9, R10, R11, R12, R14, R15 and R16) and then to provide cigarettes for all of the residents, including those who did not pay for the cigarettes, and then place them into a communal container…

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 obtain a consent for bedrails, failed to assess the use of physical restraints timely, failed to include physical restraints on the care plan and failed to provide medical reasoning for physical restraints for one (R3) resident out of three residents reviewed for accidents in a sample list of three residents. Findings include: R3's Undated Face Sheet documents R3 admitted to facility on 5/23/23. This same Face Sheet documents R3's Medical Diagnoses of Dementia, Anxiety Disorder, Psychosis, Restless Leg Syndrome, Sensorineural Hearing Loss, Dependence on Wheelchair, Difficulty in Walking, Dysphagia and Repeated Falls. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as severely cognitively impaired. This same MDS documents R3 as requiring extensive assistance of one person for bed mobility, dressing, personal hygiene, and toileting, and extensive assistance of two people for transfers. R3's Physician Order Sheet (POS) dated November…

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 and notify the Abuse Coordinator/Administrator of alleged abuse for one resident (R1) of three residents reviewed for abuse in the sample of nine. Findings include: R1's undated Face Sheet documents R1's diagnoses as Unspecified Dementia, Unspecified Severity with other Behavioral Disturbances; Unspecified Mood Disorder; Mild Cognitive Impairment; and Unspecified Intellectual Disabilities. R1's Minimum Data Set (MDS) dated [DATE], documents R1 is cognitively intact. R1's Care Plan dated 8/31/23, documents R1 has impaired cognition and communication related to vascular dementia. On 9/18/23 at 2:31 PM, V9 (Certified Nursing Assistant/CNA) stated no one hit R1. V9 stated R1 told V8 (Licensed Practical Nurse/LPN) that V9 hit R1. V9 stated V8 told R1 that V9 did not hit R1. V9 stated V9 does not know if V8 reported it (alleged abuse) to anyone. V9 stated V9 wrote a report up and gave the report to V8. V9 stated she was not suspended. V9 stated she…

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