Allure Of The Quad Cities

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure blood pressure monitoring was performed after a change in condition for 1 of 3 residents (R1) reviewed for change in condition in the sample of 3. The findings include: R1's face sheet printed on 7/31/25 showed diagnoses including but not limited to left side hemiplegia and hemiparesis, psychophysiologic insomnia, epileptic syndrome, and cognitive social or emotional deficit following cerebrovascular disease. R1's facility assessment dated [DATE] showed no severe cognitive impairment. The same assessment showed R1 is capable of self-propelling her wheelchair with only supervision or touch assistance from staff. On 7/31/25 at 10:25 AM, R1 was seated in a wheelchair and easily wheeling herself down the hallway using the handrail. R1 was talkative and stated she did recall an incident about a week ago (7/24/25) when she was sitting outside. R1 said the exact details are fuzzy but she remembered staff taking her blood pressure when she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure one resident (R2) was free from sexual abuse and failed to ensure two residents (R3,R4) were free of physical, resident-to-resident abuse of five residents reviewed for abuse in a total sample of five.The Facility's undated Abuse, Neglect and Exploitation policy documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident. R1's Medical Record documents that he was admitted on [DATE] with diagnosis to include but not limited to Dementia, Insomnia and repeated falls. R1's MDS (Minimum Data Set) dated 6/3/25 documents his BIMS (Brief Interview Mental Status) score of 9/15, indicating severe cognitive impairment. R2's Medical Record documents that she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to have documented behaviors to warrant the use of antipsychotic and other psychotropic medications and the facility failed to attempt nonpharmacological interventions prior to using antipsychotic and other psychotropic medications for three residents (R1, R3 and R5) of three residents whose psychotropic medications were reviewed in a total sample of five. The Facility's undated Use of Psychotropic Medication(s) documents It is the intent of this policy to ensure that residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. The policy defines Adequate indications for use as refers to the identified, documented clinical rational for administering a medication that is based upon an assessment of the resident's…

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

Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse for one resident (R1) of five residents reviewed for abuse in a total sample of five. The Facility's undated Abuse, Neglect and Exploitation policy documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation: 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. not tampering or destroying evidence); 3. Investigating different types of alleged…

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 resident's medical records when requested for 1 of 4 residents (R1) reviewed for medical records in the sample of 4. The findings include: R1's face sheet accessed on 6/13/25 show that R1 was admitted to the facility on [DATE] and discharged on 9/19/24 with diagnosis of Parkinson's. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. (BIMS-15) On 6/13/25 at 9:35 AM, via telephone conversation with R1 and V6 (R1's sister). R1 said she wanted to get a copy of her medical records but has not gotten them yet. R1 also wanted this surveyor to speak to V6. V6 said my sister (R1) and I made a call to the Nursing Home a couple of weeks ago and spoke to V7 (Medical Record staff) requesting a copy of R1's medical record. V7 spoke to R1 to get her verbal consent. V7 said she was not sure if R1 was allowed to get a copy of her medical records so she had to ask permission from corporate first then she will call us back. V6 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify a physician of a high blood sugar for 1 of 4 residents (R2) reviewed for notification in the sample of 4. The findings include: R2's Physician Order Sheet dated 6/2025 show R2 was admitted to the facility on [DATE] and discharged on 6/1/25 with diagnoses that includes diabetes mellitus and diabetic neuropathy. On 6/13/25 at 9:47 AM, V4 (R2's son) said the time R2 was in the Nursing Home, R2 had been in the Hospital due to his blood sugar either being too high or too low. The family has a Dexcom system that's connected at home and sends triggers when R2's blood sugar is high or low. On 6/1/25 at around 2-3 in the morning, we had a trigger that showed my dad's bloods sugar was high at 400. My stepmom (V10) called the nursing home and requested the Nurse to please notify the doctor due to R1's high blood sugar but the nurse said no and refused to call my dad's physician. On 6/13/25 at 1:08 PM, V3 (Registered Nurse) said she was one of the Nurses…

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 accurate shift-to-shift controlled medication counts for all residents that had controlled medications stored on the Station C/Front Hall medication cart in the month of April 2025. This failure has the potential to affect 27 residents (R2, R6-R41). Findings include: Facility Policy/Controlled Substance Administration and Accountability dated 2025 documents: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility shall have safeguards in place in order to prevent loss, diversion or accidental exposure. Inventory Verification: For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. Medication Dispense History Report dated 4/1/25 to 4/30/25 indicates R2 and R6 - R41 had controlled medications stored in the Station C/Front medication cart. Narcotic and Controlled Substance Shift-To-Shift Count…

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 theft of controlled medications for one resident (R2) of three residents reviewed for misappropriation of property in the sample of 15. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2025 documents: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without resident consent. Facility Policy/Controlled Substance Administration and Accountability dated 2025 documents: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility shall have safeguards in place in order 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 obtain a urine specimen according to physician orders for one resident (R1) of three residents reviewed for implementing physician orders in the sample of 15. Findings include: NP (Nurse Practitioner) Note dated 4/28/25 at 10:22am indicates R1 Complaining of occasional burning pains with urination for a few days. Note indicates R1 has chronic urinary incontinence, chronic overactive bladder and history of UTI's (Urinary Tract Infections). Note Assessment and Plan indicates (obtain) UA (urinalysis) with C&S (Culture and Sensitivity) if indicted. R1's Physician Order dated 4/28/25 indicates Obtain urine sample for UA, C&S. May straight cath(eter) every shift for 2 Days. Progress Note dated 4/30/25 at 12:32am indicates Obtain urine sample for UA, C&S. May straight cath(eter) every shift for 2 Days sample contaminated. Progress Note dated 5/4/25 at 3:50pm indicates UA obtained per straight cath(eter) using sterile procedure, 100ml (milliliters) of turbid, viscous, foul smelling urine returned. (R1's) daughter at bedside and is…

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 utilize two staff members when transferring residents with a mechanical lift for two (R1 and R2) of four residents reviewed for mechanical lift transfers in the sample of eight. Findings include: The facility's policy titled Safe Resident Handling/Transfers, not dated, documents, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 10. 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.

Based on record review and interview the facility failed to ensure quality assurance meetings were held quarterly and that the facility medical director attended quality assurance meetings. This failure has the potential to affect all 94 residents residing in the facility. Findings Include: A facility policy, entitled Quality Assurance and Performance Improvement (QAPI), undated, document, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides; and 1. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) committee and a written QAPI plan. 2 The QAA committee shall be interdisciplinary and shall: a, Consist at a minimum of: i. The director of nursing services, ii. the medical director or his/her/designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, owner, a board member, or other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents electronic medical records and care plans matched the Physician's Order for Life-Sustaining Treatment (POLST) for Cardio-Pulmonary Resuscitation (CPR) code status for three of five residents (R25, R69, R74) reviewed for Advanced Directives in a total sample of 39 residents. Findings include: The facility's Residents' Rights Regarding Treatment and Advance Directives policy, undated, documented It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident. The Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form's section A has two options to choose from if the patient has NO pulse: attempt CPR…

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

Based on interview and record review the facility failed to revise an antipsychotic medication care plan and a dialysis care plan for two residents (R12, R23) of 19 residents reviewed for care plans in the sample of 39. Findings include: Facility Policy/Comprehensive Care Plans dated 2024 document, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. Current Physician Order Summary Report indicates R12 receives: Clozapine (atypical Antipsychotic) 25mg (milligrams) Give 1 tablet by mouth every 2 hours as needed for Neuromuscular with Lewy Body Dementia (as needed can take 2 hours up to 3 Tabs in 24 hours) (re-order date 11/15/24); Clozapine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure physician orders for dialysis were written and communication sheets were completed for two of two residents reviewed for dialysis (R23, R87) in a sample of 39. Findings include: A facility policy titled Hemodialysis, 2023 documents, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. A section titled Purpose documents: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer a medication to prevent EPS (Extrapyramidal Symptoms) in conjunction with an antipsychotic medication according to physician orders for one resident (R12) of five residents reviewed for psychotropic medications in the sample of 39. Findings include: Facility Policy/Medication Errors dated 2024 document, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. The facility shall ensure medications will be administered as follows: According to physician orders. In accordance with accepted standards and principles which apply to professionals providing services. Medication errors once identified will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: Resident Condition Drug Category Frequency of Error - If an error is…

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

Based on observation, record review and interview the facility failed to ensure enhanced barrier precautions were followed for one resident (R78) of two residents reviewed for infection control in a total sample of 39. Findings include: An undated policy, entitled Enhanced Barrier Precautions (EBP) document, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy further documents, 4. High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, peripherally inserted central catheters, midline catheters and wound care. R78's 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.

Based on interview and record review the facility failed to ensure one resident (R1) was free of mistreatment of three residents reviewed for abuse. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2023 documents: The facility will develop and implement written policies that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment means inappropriate treatment or exploitation of a resident. Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their…

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 initiate and implement Enhanced Barrier Precautions for 24 residents (R1, R2, R3, R6, R8 - R27) reviewed for Infection Control practices of 26 residents reviewed. This failure has the potential to affect all 95 residents who reside in the facility. Findings include: Facility Policy/Enhanced Barrier Precautions dated 3/2024 documents: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities. Prompt recognition of need: All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. Initiation of Enhanced Barrier precautions: An order for enhanced barrier precautions will be obtained for residents with any 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 record review and interview the facility failed to prevent misappropriation of property for one resident (R1) of 3 residents reviewed for misappropriation of property in the sample of 8. Findings Include: Controlled Substance Administration and Accountability, dated 2023, documents the following. It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion, or accidental exposure. The Facility Reported Incident, with Date of Occurrence dated: 1/19/2024, Incident Category: Resident Misappropriation of Property/Theft. Incident Description: Missing medications noted for R1. Per Pharmacy: Hydrocodone 5/325MG (Narcotic pain reliever) with a quantity of (89) tablets delivered on 1/5/2024. V3/Unit Manager signed for the medication and processed them in. V3 states there were 2 cards, one with a quantity of (44) tablets and the second card with (45) tablets. V3 said V3 placed both narcotic cards 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 record review and interview the facility failed to prevent an occurrence of staff-to-resident verbal abuse from occurring for one of three residents (R1), reviewed for abuse in the sample of 6. Findings Include: The undated facility policy, Abuse, Neglect and Exploitation documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident altercations. It also includes verbal abuse. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. The…

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 its abuse policy of immediately reporting potential abuse, protecting a resident from further potential abuse, and investigating an allegation of potential abuse for one of three residents (R1) reviewed for abuse in the sample of 6. FINDINGS INCLUDE: The undated facility policy, Abuse, Neglect and Exploitation, directs staff, The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property; and Establish policies and procedures to investigate any such allegation. On 01/25/24 at 8:26 A.M., V1/Administrator, Abuse Coordinator stated, I became aware of a situation (potential verbal abuse 12/21/23 at 6:15 P.M.) between (R1) and (V8/Certified Nursing Assistant) on 12/22/23 at around 8:15 AM. I didn't report the incident to the (state agency), suspend the (CNA V8/Certified Nursing Assistant) or begin an investigation until 12/22/23 at 9:15 A.M. The (facility) Investigation Report, dated 12/22/23 at…

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

Based on interview and record review, the facility failed to failed to ensure one allegation of abuse was immediately reported to the Administrator for one of three residents (R1) reviewed for abuse, in the sample of 6. FINDINGS INCLUDE: The facility Incident Initial Report, dated 12/22/23 and completed by V1/Administrator documents, At 8:15 AM, (R1) reported that a CNA (Certified Nursing Assistant) named '(V8/Certified Nursing Assistant/CNA)' refused to give (R1) coffee when (R1) requested it after the supper meal. When (R1) went to pour it himself, (V8/CNA) smacked (R1's) hand and told (R1) no. (R1) assessed for injury, none noted, and (R1) denies pain at this time. CNA identified as (V8) and suspended immediately, pending investigation. POA (Power of Attorney) and Physician notified. Investigation initiated. On 01/25/24 at 8:26 A.M., V1/Administrator, Abuse Coordinator stated, I became aware of a situation (potential verbal and/or physical abuse 12/21/23 at 6:15 P.M.) between (R1) and (V8/Certified Nursing Assistant) on 12/22/23 at around 8:15 AM. I didn't report the incident 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 provide the resident council with responses, actions, and rationales taken regarding their concerns. This has the potential to affect all 96 residents residing within the facility. Findings include: The facility's Resident and Family Grievances policy, dated 2023, documents, Grievances may be voiced in the following forums: Verbal complaint to a staff member or Grievance Official; Written complaint to a staff member or Grievance Official; Written complaint to an outside party; Verbal complaint during resident or family council meetings; Via the company toll free Customer Service line. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form: Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up; All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official.…

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

Based on interview and record review, the facility failed to provide a sufficient number of staff to provide assistance to dependent residents. This failure has the potential to affect all 96 residents residing within the facility. Findings include: The facility's Nursing Services and Sufficient Staff policy, dated 2/23, documents, It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment. The facility's Call lights: Accessibility and Timely Response policy, dated 2/23, documents, All staff who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. On 12/06/23 at 11:09 a.m., during the survey resident council meeting the following resident statements were…

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

Based on observation, interview, and record review, the facility failed to serve food at a palatable temperature. This has the potential to affect all 96 residents residing in the facility. Findings include: The facility's Resident Council Minutes, dated 9/26/23, document that the residents have concerns with the food being cold. On 12/05/23 at 11:30 AM, upon entering the kitchen two insulated meal cart's doors were open. and contained trays of meals. One cart contained meals that were not on a hot plate. On 12/05/23 from 11:30 to 11:45 AM, throughout this observation, V4 (Dietary Manager) was present. The two meal cart doors remained open, and the one cart of meals were not on hot plates. V4 stated, All of our meals are sent out on carts and taken to the halls. All of the plates should be on top of a hot plate and covered with an insulated cover. The meal cart that is open and has no hot plates is the Arcadia Hall trays. The meal cart doors should always be closed to keep the heat in. V4 yelled to her staff, Why aren't Arcadia plates on hot plates? V21 replied, We don't have enough…

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 recognize signs and symptoms of illness of facility staff and residents as a possible contagious illness (RSV, COVID-19, Influenza), failed to perform the required COVID-19 testing on staff and residents actively demonstrating signs and symptoms of a possible infectious respiratory illness, failed to test for other infectious respiratory illnesses (RSV and influenza) when a COVID-19 test was negative, failed to implement isolation precautions with symptomatic residents, and failed to ensure a surgical mask covered the staffs' mouth and nose while serving food. These failures had the potential to affect all 96 residents residing within the facility. Findings include: The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, documents, Anyone with even mild symptoms of COVID-19, regardless of…

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

Based on observation, interview, and record review, the facility failed to designate an onsite staff member as Infection Preventionist. This has the potential to affect all 96 residents residing in the facility. Findings include: The facility's QAPI (Quality Assurance and Performance Improvement) Committee Meeting Attendance Records, dated 3/7/23, 6/6/23, and 9/5/23, document that V12 (Regional Nurse) is the Infection Preventionist. On 12/04/23 at 02:53 PM, V1 (Administrator in Training) stated, (V2/ Director of Nursing) is currently being trained to become our Infection Preventionist. V12 is an Infection Preventionist, but she doesn't work in our building on a full time basis. She is training (V2). On 12/05/23 at 10:15 AM, V2 stated, Our outbreak started on 11/10/23 when a staff member tested positive. I'm the Infection Preventionist, but I haven't completed the Infection Preventionist training yet. During this outbreak, we've had 24 residents and 24 staff test positive for COVID. On 12/07/23 at 11:01 AM, V12 stated, I have been filling in as the Infection Preventionist since March…

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 smoke detector was not covered causing it to be inoperable and not providing smoke protection. This failure has the potential to affect all 96 residents residing in the facility. Findings include: According to the National Safety Council, dated 2023, about three out of five fire deaths happen in homes without working smoke alarms. Smoke alarms are a key part of a home fire escape plan providing early warning to reduce your risk of dying in a fire. On 12/04/23 at 10:45 AM, a fire alarm was installed on the ceiling of the kitchen located near the exhaust hood (approximately five feet). The fire alarm was covered with clear plastic, and the plastic was secured around the alarm's perimeter with painter's tape. V4 (Dietary Manager) stated, We have the fire alarm covered with the plastic, because if we do not keep it covered, it will alarm every time we open the steamer, and then the fire department has to come to the building. On 12/4/23 at 2:25 p.m., V4 stated, We removed the plastic from the smoke…

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 treat residents with dignity by serving their meal fluids in disposable cups. This has the potential to affect all 29 residents (R2, R4, R5, R7, R11, R13, R17, R19, R22, R28, R30, R32, R33, R40, R42, R45, R54, R56, R60, R63, R65, R66, R68, R69, R71, R77, R80, R87, R295) residing on the Arcadia unit in the sample of 48. Findings include: The facility's Promoting/Maintaining Resident Dignity policy, dated 2/23, documents, It is the practices of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. On 12/05/23 at 12:00 PM, the Arcadia meal tray cart was outside of the dining room. Staff were serving the residents their meal trays. Residents were served their milk, water, and juice in disposable clear cups and disposable Styrofoam cups. On 12/05/23 at 12:16 PM, V23 (CNA-Certified Nursing Assistant)…

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 range of motion exercises for one of one resident (R25) with a known history of limited range of motion, in a sample of 48. Findings include: The (undated) facility policy, Prevention of Decline in Range of Motion, directs staff, residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Staff will be educated on basic, restorative nursing care. This training may include: Assisting residents with range of motion exercises, performing passive range of motion for residents unable to participate. General Guidelines for Range of Motion: Explain the procedure to the resident then ask permission to proceed. Move each joint through its range of motion three times unless otherwise instructed. Move each joint gently, smoothly, and slowly through its range of motion. Stop an exercise before the point of pain. Report pain to the nurse. R25's admission…

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 check placement of a gastrostomy feeding tube prior to the administration of fluids and medications; and failed to flush a gastrostomy feeding tube with the prescribed water flushes between medications for one of one resident (R70), reviewed for feeding tubes, in a sample of 48. Findings include: The (undated) facility policy, Medication Administration via Enteral Tube directs staff, It is the facility policy to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines. Enteral tube placement must be verified prior to administering any fluids or medication. Flush enteral tube with at least 15 ML (milliliters) of water prior to administering medications unless otherwise ordered by prescriber. Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe. Flush tube again with at least 15 ML of water taking into account resident's volume status. Repeat with next medication. Flush the tube with a final flush of 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 ensure pain medication was available upon admission for a resident with reports of pain for one of one resident (R145) reviewed for pain in the sample of 48. Findings include: On 12/06/23, V2 (Director of Nursing) provided a copy of (contracted pharmacy's) undated policy titled 'New admission Policy & Procedure' and stated this policy is utilized by the facility in collaboration with (contracted pharmacy). This same policy documents the following: Process to provide medications prior to the next scheduled delivery: Review contents of the aforementioned boxes (E box or C box) that are on-site at the facility and with the nurse, confirm needed medications are available. If not, medications will either be: sent STAT (immediately) from the pharmacy or called into a local pharmacy and a courier scheduled by pharmacy will pick up the medication and deliver to the facility. If there is a control necessary and we do not have the medication or we…

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 document a rational for the continued use of an antibiotic for one of one resident (R25) reviewed for unnecessary medications in a sample of 48. Findings Include: The (undated) facility policy, Antibiotic Stewardship Program directs staff, The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. All prescriptions for antibiotics shall specify the dose, duration and indication for use. R25's Physician Order Sheet, dated 12/5/2023 includes the following medication: Cefdinir Capsule 300 MG Give 1 capsule by mouth one time a day for maintenance. No stop date is included for the antibiotic usage. On 12/4/23 at 3:09 P.M., V2/Director of Nurses stated, (R25) is on continuous antibiotics due to recurrent knee wound infections. I didn't realize the antibiotic was started that long ago. There is no stop date for the medication. On 12/5/2023 at 8:10 A.M., V8/Wound Doctor stated, I have no idea why (R25) is on a maintenance dose of antibiotic. (R25) doesn't…

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 antibiotics were prescribed appropriately for one of one resident (R25) reviewed for antibiotic use in the sample of 48. Findings include: The facility's Antibiotic/Antimicrobial Stewardship Program policy (dated 11/28/17) documents the following: This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the use of antibiotics. This program helps ensure that our residents get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections, and healthcare costs. This policy also documents, Review the clinical record for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with the antibiotic stewardship practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to identify specific target behaviors; and monitor and track behaviors for three residents (R2, R55, R69) of four residents reviewed for psychotropic medications in the sample of 21 residents. Findings include: The Facility's Psychotropic drug use policy dated 5/20/2022 documents Long-term care residents with dementia commonly display behavioral and psychological symptoms of dementia, such as agitation, wandering, aggression, and sleep disturbances, resulting in treatment with psychotropic drugs. A psychotropic drug is defined as any drug that affects brain activities associated with mental processes and behaviors. - Identify the date, time, and location of the resident's specific behavior that's causing concern as well as any identified triggers. Gather information from staff members who have witnessed the behavior. - Use a behavior monitoring tool to identify the frequency, intensity, duration, and impact of the resident's behavior. -…

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.