Arcadia Care Morris

Based on observation, interview, and record review, the facility failed to perform hand hygiene and follow enhanced barrier precautions. This applies to 3 of 3 (R6, R7 and R12) residents reviewed for infection control in a sample of 25. Findings include: 1. On 4/29/25 at 1:06 PM, observed R6 being wheeled into his room by V8 (CNA-Certified Nursing Assistant), followed by V10 (CNA) with a mechanical lift to transfer R6 from his wheelchair to bed. R6 had a urinary catheter. Outside of R6's room on the wall was a poster stating R6 is on EBP (Enhanced Barrier Precautions). Neither V8 nor V10 wore gowns. V8 provided perineal care to R6 without wearing a gown. After wiping the buttocks and genitals of R6, V8 did not remove the soiled gloves or perform hand hygiene and applied a fresh clean disposable brief. Wearing the same soiled gloves, V8 adjusted R6's bed linen and then, removed her gloves, tied up the garbage bag, touched the door and the doorknob, and left the room, all without performing hand hygiene. On 4/29/25 at 1:15 PM, V6 (LPN-Licensed Practical Nurse) walk into the room of R6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their water management plan for legionella. The facility also failed to follow their policy for enhanced barrier precautions, transmission based precautions, and hand hygiene during provisions of care. This applies to all 72 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated September 30, 2024, showed the facility's census was 72 residents. On October 1, 2024, at 3:18 PM, V27 (Environmental Services Director) said he does not keep documentation of the temperatures of the hot water boiler/storage tanks, the thermostat of the mixing valve, eye wash station inspections and flushing, ice machine inspections and cleaning, and cooling tower inspections. On October 2, 2024, at 9:40 AM, V27 provided the water temperatures he has documented from July 1, 2024, to present. V27 said these are the only water temperatures he records for the facility. 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 assist residents identified as needing assistance with personal hygiene and grooming. This applies to 7 of 8 residents (R3, R8, R12, R30, R44, R63 and R67) reviewed for ADLs (activities of daily living) in the sample of 18. The findings include: 1. R8 had multiple diagnoses including dementia without behavioral disturbance and age related macular degeneration of both eyes, based on the face sheet. R8's quarterly MDS (minimum data set) dated July 25, 2024, showed that the resident was severely impaired with cognition and required assistance from the staff with personal hygiene. On September 30, 2024, at 10:42 AM, R8 was in bed, alert, verbally responsive but confused. V6 (Certified Nursing Assistance) was in the resident's room and had placed a blanket on the resident. V6 requested R8 to show her hands and fingers. R8's fingernails were long with black substances under most of her nails. During the lunch meal observation on September 30,…

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 serve mechanical soft consistency mushrooms and potatoes and failed to serve pureed consistency chicken and vegetables for residents on mechanical soft and pureed diets. This applies to 9 of 9 residents (R1, R6, R10, R15, R24, R26, R30, R41 and R224) reviewed for mechanically altered diets in the sample of 18. The findings include: 1. On September 30, 2024, at 12:07 PM, during meal temperature monitoring of prepared foods prior to meal service, the pureed chicken on the tray line appeared grainy. On taste testing, there were parts of the pureed chicken that were not able to be swallowed without being chewed. V8 (Regional Dietary Certified Manager) who was in the vicinity was notified and was informed that the item was not safe to serve. V8 also taste tested the product and agreed with the consistency and stated that the pureed meat should not be uneven and should be like mashed potatoes. On October 1, 2024, at 11:53 AM, during tray line…

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 respond to a resident's call for help and failed to ensure that the call light was always within reach of the resident. This applies to 1 of 18 residents (R12) reviewed for call light accessibility in the sample of 18. The findings include: Face sheet shows that R12 has multiple medical diagnoses which include cervical disc degeneration unspecified cervical region, spinal stenosis cervical region, spondylosis without myelopathy or radiculopathy cervical region, fusion of spine cervical region, morbid (severe) obesity due to excess calories, other lack of coordination, abnormal posture, reduced mobility, and weakness. Minimum Data Set (MDS) dated [DATE], shows R12 is alert and oriented and is totally dependent of staff for dressing and toileting hygiene. On October 1, 2024, at 10:56 AM, R12 was observed repeatedly yelling for help. V25 (Housekeeper) was outside R12's bedroom cleaning and continued to do her chores despite R12's repeated…

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 assess and provide splints to a resident, to prevent further reduction in ROM (range of motion). This applies to 1 of 4 residents (R63) reviewed for range of motion in the sample of 18. The findings include: R63 has multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and weakness, based on the face sheet. R63's quarterly MDS (minimum data set) dated July 25, 2024, showed that the resident was cognitively intact. The MDS showed that the resident had impairment in range of motion on one side of her upper extremity. The same MDS showed that R63 required maximum to total assistance from the staff with her ADL's (activities of daily living). On September 30, 2024, at 11:04 AM, R63 was in bed, alert, oriented and verbally responsive. R63 had weakness on her right arm, and her right hand and wrist appeared contracted. R63 was not able to move her right arm and hand without the help of her left hand. R63 had no splint or positioning device on her right…

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

Based on observation, interview, and record review, the facility failed to ensure that urinary catheter tubing and bag are always below a resident's bladder to prevent potential urine backflow. This applies to 1 of 2 residents (R3) reviewed for catheter care in the sample of 18. The findings include: Face sheet shows that R3 is 85 years-old who has multiple medical diagnoses which include multiple sclerosis, neuromuscular dysfunction of the bladder, personal history of urinary tract infection (UTI), cystostomy, and hydronephrosis. On September 30, 2024, at 10:32 AM, V22 and V23 (both Certified Nursing Assistants) were seen providing care to R3. V22 said they just finished the incontinence care. V22 and V23 were repositioning R3 and straightening her bed linens. R3 has a suprapubic catheter and nephrostomy catheter tube. V23 positioned the suprapubic catheter and nephrostomy catheter tube and bag on top of the pillow that was above R3's bladder. On September 30, 2024, at 4:10 PM, the suprapubic and nephrostomy catheter tubing and nephrostomy bag remained positioned on top of the…

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

Based on observation, interview and record review, the facility failed to provide breakfast meals for a resident who is on dialysis treatment. This applies to 1 of 2 residents (R41) reviewed for dialysis in the sample of 18. The findings include: R41's EMR (electronic medical records) showed that R41 was admitted to facility on August 27, 2024, with diagnoses including Parkinson's disease with dyskinesia, with fluctuations, unspecified acute kidney failure, dependence on renal dialysis and dementia with other behavioral disturbance. R41's MDS (minimum data set) dated September 2, 2024, showed that R41 was moderately impaired in cognition. R1's active POS (Physician Order Sheet) showed Dialysis Treatments 3 (Three) times a Week at 2:30 PM, which was revised to 6:15 AM on October 2, 2024. Facility provided information that R41 switched from afternoon schedule at 2:30 PM to early morning schedule at 6:15 AM for dialysis on September 23,2024. R41's active POS included diet order of Regular diet, Mechanical Soft texture, thin consistency, Renal Diet supervised feeding, cues for 1 bite at…

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

Based on observation, interview, and record review, the facility failed to ensure that the residents central line insertion sites were visible under a transparent dressing for assessment. The facility also failed to ensure that the central line dressings were clean and intact. This applies to 2 of 2 residents (R124 and R174) reviewed for IV (intravenous) central line in the sample of 18. The findings include: 1. Face sheet shows that R174 has multiple diagnoses which include discitis, unspecified thoracolumbar region, and extradural and subdural abscess. On September 30, 2024, at 11:06 AM, R174 was in her bedroom resting. R174 had an IV central line on her right chest, with the insertion site covered with a non-transparent tape. The edges of the dressing were rolled up and showed brown substances (dirt) that adhered to the rolled up or peeling edges. R174 said that she has discitis osteomyelitis. On September 30, 2024, at 1:23 PM, V12 (Nurse) said R174 has an IV central line, and she changed the dressing on September 26, 2024. On October 2, 2024, at 10:45 AM, R174 was sitting in 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 ensure a resident did not receive antipsychotic medications without indications for use. This applies to 1 of 5 residents (R43) reviewed for psychotropic medications in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R43 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R43's MDS (Minimum Data Set) dated August 29, 2024, showed R43 had severe cognitive impairment. The MDS continued to show R43 did not have any behavioral symptoms. R43's Order Summary Report dated October 2, 2024, showed Risperidone (Antipsychotic medication) oral tablet 1 mg (milligram), give half tablet by mouth four times a day for restlessness. R43's anti-psychotic medication care plan date June 21, 2023, showed The resident is receiving anti-psychotic medications…

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

Based on interviews and record reviews, the facility failed to have a full time RN (Registered Nurse) as the facility's DON (Director of Nursing). This affects all 81 residents at the facility reviewed for staffing. The 12/5/23 CMS-671 form showed 81 residents live in the building. On 12/07/23 at 4:24 PM, V2 DON said, I am an LPN (Licensed Practical Nurse) full time. I am the only DON. V2 said the facility knew that the DON is supposed to be an RN. V2 said that she has been the DON since July of 2023. V2 said that I have been the DON and V21 (Operations Consultant), the administrator at that time, told me he knew that the DON needs to be an RN, but he put me in the position anyway. On 12/07/23 at 4:13 PM, V1 (Administrator) said he did not know if V2 was an RN or not. The facility's Lookup Detail View from Illinois Department of Financial and Professional Regulation showed V2 as an LPN in active status, effective 1/9/23, and expiration date of 1/31/25.

Based on observation, interview and record review the facility failed to serve food in a sanitary manner. This applies to all 81 residents reviewed for sanitary food storage and preparation. The findings include: The 12/5/23 CMS-671 form showed 81 residents live in the facility. 12/05/23 09:45AM V4, [NAME] and V3 FSD (Food Service Director) were in the kitchen area preparing lunch. A large garbage can was next to food prep table and the steam table and open to air. A multitude of refuse was piled high with a pair of bags and gloves with a blood like substance dripping off. A cleaning rag and a cellular phone was on top of the food prep table across from the stove. There was a large buildup of scale (beige debris) in steam table wells. Water has particles floating in it. Overall, the food preparation area has debris on the floor and under the steam table and several carts. The log for sanitizing sink is not consistently filled out. The log for food temps not done since 12/3/23. General floor is dirty. Shelves under steam table dirty. A large beef roast was on the prep table area near…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents receive regular bathing, grooming and assistance with activities of daily living. This failure applies to 6 residents. (R18, R38, R43, R56, R64 and R68) in the sample of 31 residents reviewed for assistance with activities of daily living. The findings include: 1. On 12/05/23 at 11:13 AM at the nursing station R18 was sitting in a dirty high back recliner. The seat, the back and the arms of the chair have a thick dark substance with some loose debris. R18 has no left eye and dry skin can be seen inside of the socket. R18 had many growths of skin on his face. One lesion was bleeding slowly with blood crusting and sticking to his overgrowth of facial hair. R18 had jagged nails with black debris under the nails. R18's clothing had dried food debris on the shirt and the pants. R18 had an odor. R18's hair is oily and has a white scaly substance on the scalp. R18 does not answer any questions. When staff was asked who was caring…

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 store active medications safely and discard outdated medications. This applies to 3 of 5 residents (R7, R15, and R62) reviewed for medication storage in a sample of 31. The findings include: 1. On [DATE] at 9:47 AM, the cart that housed R7's medications was checked with V13 LPN (Licensed Practical Nurse). A Tiotropium Bromide 18 MCG (Microgram) inhaler prescribed for R7 expired 10/ 2023. A blister pack of Lorazepam 0.5 MG (Milligrams) prescribed for R6 had one blister opened and retaped. A blister pack of Tramadol 50mg prescribed for R7 had three blisters opened two were retaped. On [DATE] at 10:05 AM, the the cart that housed R15's medications was checked with V13 LPN. A medicine cup filled with pills was observed. V13 stated they were morning medications for R15. The medication cup was not labeled with contents or R15's name. A blister pack of Lorazepam 0.5 MG prescribed for R15 had one pill that had been opened and retaped. On [DATE]…

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 temperature logs and label food items in residents' personal refrigerators and failed to discard outdated food items. This applies to 6 of 6 residents (R24, R26, R47, R52, R64 and R184) reviewed for personal food storage. The findings include: 1. On 12/05/23 at 11:03 AM inside of R24's refrigerator, there were eight half pint cartons of expired milk. The dates of expiration ranged from 10/30/23 (over a month earlier) through 11/21/23. A meat sandwich dated 11/19/23 and one low fat yogurt with best by date of 12/18/22 was inside of the refrigerator. Two small cups containing pickles and mayo were in the refrigerator without a date. On 12/06/23 at 09:45 AM R24 said the only thing in the refrigerator is milk, pop and ice cream. R24 said she cleans the refrigerator out every couple of weeks. R24 said the CNAs (Certified Nursing Assistant) working on the unit check the refrigerator daily for old and expired foods. On 12/06/23 at 09:56…

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 observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medication and obtain a physician order for resident medication to be at the bedside. This applies to 1 resident (R62) reviewed for medication self-administration in the sample of 31. Findings include: R62 is an [AGE] year old female admitted to the facility on [DATE]. On 12/05/23 at 11:19 AM, 2 bottles of Fluticasone propionate 50 mcg nasal spray (nasal steroid used to decrease inflammation in nose) were observed on R62's bedside table. R62 said she uses them herself every morning. On 12/07/23 at 9:38 AM, V2 DON (Director of Nursing) said that R62 doesn't have an order to self-administer medication and has not had an assessment to see if she could self-administer medications. V2 said R62 does not have an order for Fluticasone propionate 50 mcg nasal spray, and the medications should not be at bedside. V1 said medication should only be in residents' rooms if they are locked in a box and if…

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 observations, interviews and record reviews, the facility failed to assist in the application of ordered braces. The facility failed to assist with clothing changes. This applies to one resident (R26) reviewed for brace use in a sample of 31. The findings include: On 12/05/23 at 11:15 AM, R26 stated she has neck, left shoulder and right leg pain. R26 stated she was told by V2 DON (Director of Nursing) and V19 CNA (Certified Nursing Assistant) she is a standby assist, and she can do things for herself. R26 stated she often does not receive staff assistance with showering or application of her brace and sling. R26 stated because she is overweight and has chronic pain, she is unable to put her sling and brace on without staff assistance. R26 stated sometimes wearing the sling makes her feel more comfortable. R26 stated when she has to walk around without the brace, she has more pain. On 12/06/23 at 9:46 AM, R26 was observed walking without her shoes, braces, or arm sling. R26 had the same clothes on from the previous day. R26 stated she had been walking around since 8:30 AM.…

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 prepare foods to residents' liking. This applies to 3 residents (R40, R77, and R185) out of 32 residents reviewed for meal satisfaction. 1. On 12/5/23 at 12:18 PM, R40 said she can't stand the food. R40 said the French fries are cold and hash browns are limp and cold. R40's POS (Physician Order Sheet) shows she is on a no added salt diet. R40's MDS (Minimum Data Set) dated 11/14/23 shows her cognition is intact. R40's Care Plan dated 11/20/23 shows R40 is at increased nutritional risk related to anemia and hypertension. Interventions include, prepare and serve diet as ordered. 2. On 12/5/23 at 12:31 PM, R77 said the food is a concern, she can't eat it and it is always cold. R77's POS shows she is on a no added salt diet. R77's Care Plan dated 11/21/23 shows R77 is at an increased nutritional risk related to malnutrition. Interventions include, Prepare and serve diet as ordered. On 12/7/23 at 12:54 PM, V2 (DON/Director of Nursing) said…

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.

Deficiency resulted in two deficient practice statements. 1. Based on observation, interview, and record review the facility failed to ensure a dishwasher temperature reached manufacturer's guidelines and failed to ensure foods and fluids were covered during transport to the residents' rooms. These failures have the potential to affect all 84 residents residing in the facility. 2. Based on observation, interview, and record review the facility failed to ensure the kitchen floor was maintained in a sanitary condition. This failure has the potential to affect all 84 residents residing in the facility. The findings include: The CMS-672 Resident Census and Conditions Report dated 2/14/2023 shows a facility census of 84. 1.a. On 2/15/23 at 12:10 PM, the dishwasher temperature gauge reading was observed to be at 100 degrees Fahrenheit. On 2/15/23 at 12:10 PM, V4 (Dietary Manager) said the temperature gauge was showing 100 degrees Fahrenheit. V4 said the dishwasher was a low temperature dishwasher. V4 said the temperature for a low temperature dishwasher should be between 120 - 140…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents dependent upon staff for bathing received scheduled showers for 4 of 5 residents (R5, R15, R28, R35) reviewed for activities of daily living in the sample of 22. The findings include: 1. R35's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include enterocolitis due to clostridium difficile, end stage renal disease, Type 2 Diabetes with diabetic peripheral angiopathy without gangrene, muscle weakness, fluid overload, and hypertensive heart and chronic kidney disease. R35's facility assessment dated [DATE] showed she has no cognitive impairment and requires extensive assist for all cares. R35's shower documentation showed she received a bed bath on 1/25/23 and her next shower occurred on 2/2/23 (1 week without a shower). R35's shower documentation through 2/17/23 showed her last shower was given on 2/5/23 (12 days without a shower). On 2/14/23 at 10:30 AM, R35 was sitting in her room in 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 ensure food was served at a palatable temperature for 4 of 4 residents (R28, R32, R35, R39) reviewed for food in the sample of 22. The findings include: 1. R28's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure, Type 2 Diabetes, major depressive disorder, chronic kidney disease, and protein calorie malnutrition. R28's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires staff assistance for most cares. On 2/15/23 at 10:23 AM, R28 said the food is cold all the time. R28 said one day was particularly bad and the dietary staff member asked the residents to bear with him because he was the only one in the kitchen that day. 2. R32's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include adrenocortical insufficiency, Type 2 Diabetes, morbid obesity, right knee pain, hyperlipidemia, lumbago with sciatica, conversion disorder…

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's chosen advanced directive was in place for 1 of 1 resident (R35) reviewed for advanced directives in the sample of 22. The findings include: R35's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include enterocolitis due to clostridium difficile, end stage renal disease, Type 2 Diabetes with diabetic peripheral angiopathy without gangrene, muscle weakness, fluid overload, and hypertensive heart and chronic kidney disease. R35's facility assessment dated [DATE] showed she has no cognitive impairment and requires extensive assist for all cares. On [DATE] at 9:54 AM, R35's Physician Order Sheet included an order dated [DATE] which showed Full Code. R35's medical record included a POLST (Physician's Order for Life Sustaining Treatment) form signed by a physician on [DATE] and uploaded into her chart on [DATE] which showed R35 had chosen to be a DNR (Do Not Resuscitate). R35's medical record…

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 coordinate a dermatology referral per physician recommendation for 1 of 2 residents (R52) reviewed for quality of care in the sample of 22. The findings include: R52's electronic face sheet printed on 2/17/23 showed R52 has diagnoses including but not limited to orthopedic aftercare, osteomyelitis, chronic obstructive pulmonary disease, type 2 diabetes, hypertension, and morbid obesity. R52's facility assessment dated [DATE] showed R52 has no cognitive impairment. On 2/14/23 at 10:14 AM, R52 stated, I started getting a rash when I first got here. They have given me itching pills and lotion. The doctor has seen me but I don't think a dermatologist has seen me. I'm not even sure they're doing anything else about my rash. R52's physician's orders showed, 12/12/22-12/17/22 Prednisone 40 mg daily x 5 days for rash, 12/19/22 wash resident back with cool water and light soap. Rinse. Pat dry. Apply castor oil liberally to back and buttocks,…

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 position a resident's (R73) urinary catheter drainage bag in a manner to prevent urinary tract infections for 1 of 1 resident reviewed for catheter care in the sample of 22. The findings include: R73's electronic face sheet printed on 2/17/23 showed R73 has diagnoses including but not limited to type 2 diabetes, peripheral vascular disease, morbid obesity, urinary retention, and chronic kidney disease stage 3. R73's facility assessment dated [DATE] showed R73 has no cognitive impairment and uses an indwelling urinary catheter. R73's care plan dated 12/17/22 showed, The resident has an indwelling catheter related to urinary retention. On 2/14/23 at 11:51 AM, R73 was being assisted from his bed to his wheelchair via mechanical lift. V15 (Certified Nursing Assistant/CNA) placed R73's urinary catheter drainage bag on the mechanical lift sling at R73's chest level (above the level of the bladder). R73's urine was observed back flowing into 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 ensure a resident's peripheral intravenous (IV) line was inserted in a manner to prevent infection. This failure applies to 1 of 2 residents (R70) reviewed for IV line insertion in the sample of 22. The findings include: R70's electronic face sheet printed on 2/17/23 showed R70 has diagnoses including but not limited to type 2 diabetes, uterine cancer, hypertension, and protein-calorie malnutrition. R70's nursing care plan dated 2/8/23 showed, DRIPT IV infusion - resident is participating in the DRIPT IV infusion. On 02/14/23 at 10:30 AM, V13 (Registered Nurse) inserted a peripheral IV line on R70's left arm. V13 did not wash his hands before starting the procedure. After accessing the vein, V13 removed the stylet (needle) and placed it on R70's bed. V13 did not remove his gloves or perform hand hygiene following the insertion of R70's IV. With the contaminated gloves on, V13 obtained R70's vital signs with reusable medical equipment. V13 then removed his gloves and did not perform hand hygiene upon exiting…

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 received oxygen as ordered by a physician for 2 residents (R78, R68) and failed to ensure respiratory equipment was stored in a manner to prevent contamination for 1 resident (R11). These failures apply to 3 of 4 residents reviewed for oxygen therapy in the sample of 22. The findings include: 1. On 2/14/23 at11:44 AM, R78 had her nasal cannula on for oxygen therapy. R78's nasal cannula was connected to the oxygen cylinder on the back of her wheelchair. The oxygen cylinder's flow meter had a needle pointing to the red area indicating empty. On 2/15/23 at 1:05 PM, R78 returned from a doctor's appointment and had been out of the facility all morning. R78's nasal cannula was connected to the oxygen cylinder on the back of her wheelchair with the flow meter needle pointing to empty. On 2/15/23 at 1:10 PM, V2 (Director of Nursing/DON) and V11 (Wound Care Nurse) observed and verified that the oxygen cylinder that R78 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, interview, and record review, the facility failed to monitor two residents (R56, R61) receiving antipsychotics for side effects and behaviors, failed to identify a medically diagnosed condition for a resident (R56) receiving an antipsychotic. These failures apply to 2 of 5 residents reviewed for psychotropic medications in the sample of 22. The findings include: 1. R56's electronic face sheet printed on 2/17/23 showed R56 has diagnoses including but not limited to anxiety disorder, restlessness and agitation, bacteremia, dementia without behaviors, and severe protein-calorie malnutrition. R56's facility assessment dated [DATE] showed R56 has mild cognitive impairment. R56's physician's orders showed, 12/7/22 Seroquel 25 mg [an antipsychotic medication] for agitation/anxiety. R56's medical record did not show any physician's orders or documentation related to monitoring resident for potential side effects or increased behaviors due to R56 receiving an antipsychotic medication. On 2/17/23 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 observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when entering a COVID-19 isolation room for 2 of 3 residents (R34 and R135) reviewed for infection control in the sample of 22. The findings include: 1. A list provided by the facility indicated R34 tested positive for COVID-19 on 02/08/23. R34's Order Review Report showed an active order for, Strict isolation - Droplet & Contact for COVID-19. The order had a start date of 2/8/23 and an ending date of 2/18/23. On 2/14/23 at 12:27 PM, on R34's room door was a sign indicating R34 was on isolation and required contact and droplet precautions. The sign indicated staff were to wear a N95 mask, gloves, and gown when entering the room. On 2/14/23 at 12:27 PM, V6 (Certified Nursing Assistant/CNA) entered R34's room to deliver a meal tray. V6 did not have on a N95 mask, gloves, or gown when entering R34's room. On 2/15/23 at 11:10 AM, V8 (CNA) said when entering a COVID-19 isolation room, such as R34's room, staff need to where a N95 mask, gloves, 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.