Arcadia Care Peoria Heights

Based on interview and record review, the facility failed to prevent abuse for one (R2) of three residents reviewed for abuse in a sample of four.Findings include: The Facility's Abuse Prevention and Reporting policy, dated 9/2024, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so the facility has attempted to establish a resident sensitive and resident secure environment The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. Facility incident report to the state surveying agency documents the following: On 06/21/2025 at approximately 9pm, (R2) stated to the nurse on duty that (R1) slapped him two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to protect a resident from resident-to-resident verbal abuse for one of three residents (R3) reviewed for abuse in the sample of seven. Findings include: The facility's Abuse Prevention and Reporting policy dated 09/2024 documents, This facility affirms the right of our resident to be free of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental, and psychosocial well-being. Verbal abuse may be…

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

Based on interview and record review the facility failed to implement their Abuse Policy to immediately report an allegation of resident-to-resident abuse to the State Surveying Agency for two of three residents (R3 and R4) reviewed for reporting of abuse in the sample of seven. Findings include: The facility's Abuse Prevention and Reporting policy dated 09/2024 documents, Any allegation of abuse or any incident that results in serious bodily injury will be reported to the (state surveying agency) immediately, but not more than two hours after the allegation of abuse. R3's Nursing Note dated 2-8-25 at 1:01 AM and signed by V4 (Licensed Practical Nurse/LPN) documents, (V4) witnessed (R4) making rude comments to (R3) as (R3) walked down the long hall on (name of hallway). (R3) stated that she felt threatened by (R4's) comments so (R3) walked down to her room grabbed her cellphone and dialed 911. The police arrived and spoke with both residents (R3 and R4) that were involved in the verbal altercation. R4's Social Service Note dated 2-11-25 at 1:28 PM and signed by V7 documents, (V7)…

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

Based on interview and record review the facility failed to implement their Abuse Policy to thoroughly investigate an allegation of resident-to-resident abuse for two of three residents (R3 and R4) reviewed for investigating abuse in the sample of seven. Findings include: The facility's Abuse Prevention and Reporting policy dated 09/2024 documents, Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation. R3's Nursing Note dated 2-8-25 at 1:01 AM and signed by V4 (Licensed Practical Nurse/LPN) documents, (V4) witnessed (R4) making rude comments to (R3) as (R3) walked down the long hall on (name of hallway). (R3) stated that she felt threatened by (R4's) comments so (R3) walked down to her room grabbed her cellphone and dialed 911. The police arrived and spoke with both residents (R3 and R4) that were involved in the verbal altercation. R4's Social Service Note dated 2-11-25 at 1:28 PM and signed by V7 (Social Service Director) documents, (V7) followed up with (R4) about previously noted…

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

Based on record review and interview the facility failed to report an allegation of potential mistreatment of a resident (R4) by a staff member to the state surveying agency after an allegation was made. Findings include: Abuse Prevention and Reporting - Illinois dated 11/28/16 documents, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is defined as, the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. If further documents, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This policy continues, Initial reporting of allegations: When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the (state surveying agency's) regional office shall be informed. A handwritten letter dated 01/26/25 and signed by V8 (Licensed Practical Nurse/LPN)…

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 a thorough investigation was conducted following a report of potential mistreatment of a resident (R4) for three residents reviewed for abuse in a sample of four. Findings include: Abuse Prevention and Reporting - Illinois dated 11/28/16 documents, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is defined as, the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. If further documents, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This policy continues, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately. This policy further documents, Upon learning of the report, the administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure competent nursing care was provided for one of one resident who sustained a fall with a head injury (R1) in a sample of four. Findings include: V3 (Medical Director's) fax dated 02/23/24 documents standing orders for all residents under V3's care which are to be implemented immediately. Residents taking any form of anticoagulant that experience witnessed or unwitnessed trauma to the head requires transport to the emergency room for evaluation. These orders were signed by V2 (Director of Nursing/DON) who was in the role of Assistant Director of Nurses at the time of signing on 02/26/24. R1's January 2025 Physician Order Summary Report documents R1 has diagnoses which include, abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy and unsteadiness on feet. R1 is prescribed Eliquis 2.5 milligrams twice daily and Aspirin 81 milligrams daily. Section GG of R1's Minimum Data Sheet documents R1 utilizes a…

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

Based on record review, observation and interview, the facility failed to label, or date refrigerated open and stored foods. The facility also failed to maintain a clean kitchen and work environment. This failure has the potential to affect all residents living in the facility except for R42 who does not receive oral intake. Findings include: The facility's Application for Medicaid and Medicare documents the facility's census was 84 on 12/01/24 with one resident who is NPO/taking nothing by mouth. The facility's Daily Cleaning Schedule, provided by V6 (Regional Dietary Manager) documents daily cleaning tasks including to Clean Stovetop/Grill. The facility's Food & Supplies: Storage policy dated 01/2024 documents; food and supply storage areas shall be maintained in a clean, safe, and sanitary manner; prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date; and all foods will be covered, labeled, and dated. On 12/01/24 at 6:25 AM metal containers with ground ham, chicken nuggets, raw sausage links and sliced turkey were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the Facility failed to maintain comfortable and safe temperature levels for five of 24 Residents (R1, R10, R20, R26, and R75) reviewed for comfortable and homelike environment in a sample of 33. Findings include: Facility Nursing Home Resident Rights Policy, undated, documents: Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law, the law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination; be treated with consideration, respect and dignity, recognizing each Resident's individuality; quality of life is maintained or improved; a homelike environment; and reasonable accommodation of needs and preferences. Facility Logbook Documentation, dated 11/26/24, documents room temperatures for room [ROOM NUMBER] (66.7 Fahrenheit/F), room [ROOM NUMBER] (69.6 F), room [ROOM NUMBER] (64.8), room [ROOM NUMBER] (66.2 F), Hall to Dining Room (68.4), Hall to…

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

Based on observation, interview, and record review, the facility failed to ensure transmission-based precautions and Enhanced Barrier Precautions were initiated and utilized per policy for two of 24 residents (R17, R286). The facility also failed to perform hand hygiene after indwelling urinary catheter care for one of three residents (R18) reviewed with indwelling urinary catheters in a sample of 33 residents. Findings include: The Infection Precaution Guidelines dated 11/2012 documented Transmission Based Precautions/Contact Precautions (TBP) are to be used for residents with known or suspected to be infected with microorganisms such as Clostridium difficile (c-diff) that can be easily transmitted by direct or indirect contact. Precaution signs will be utilized to alert staff and visitors to see the nurse for instructions prior to entering room. The Enhanced Barrier Precautions (EBP) policy dated 4/2024 documented EBP should be considered and implemented for indwelling medical devices and/or at the discretion of the Infection preventionist. 1. R286's Physician's Order dated…

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

Based on, observation, interview, and record review the facility failed to accurately document an upper extremity fracture and range of motion impairment in an MDS/Minimum Data Set for one of 24 residents (R82) reviewed for MDS accuracy in a sample of 33. Findings include: The facility was unable to provide an MDS policy. R82's medical record includes a left shoulder X-ray interpretation dated 11/01/24 by V19 (Radiology Physician) documenting an acute fracture of the distal clavicle. R82 was placed in a left arm sling on that date. R82's medical record includes a Progress Noted by V21 (Orthopedic Physician) dated 11/07/24 documents R82 had a comminuted supracondylar fracture of the left humerus and was fitted with a left long arm waterproof cast at that time. R82's medical record included a left elbow X-ray report by V17 (Radiology Physician) dated 11/06/24, documenting R82 had a supracondylar fracture of the distal left humerus/upper arm. R82's medical record includes a Nurses Note by V2 (Director of Nurses/DON), dated 11/07/24 at 3:24pm stating, (R82) returned from (orthopedic)…

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 state mental health authority after a significant change in physical condition of two residents who have a mental disorder and failed to follow facility policy on Preadmission Screening and Annual Resident Review (PASARR) for two residents (R19, R59) of eight residents reviewed for PASARR in a sample of 33. Findings include: The facility's policy titled Preadmission Screening and Annual Resident Review (PASARR), revised 11/2018, documents, Annually and with any significant change of status, the facility will complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement personalized care plans for two of 24 residents (R63, R77) reviewed for care plans in a sample of 33. Findings include: The Facility's Comprehensive Care Plan policy, revised 10/2024, documents that the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment. Findings include: 1. R63's Minimum Data Set, dated [DATE], documents a diagnosis of Non-Alzheimer's Dementia and Post Traumatic Stress Disorder. R63's current care plan does not document goals or interventions concerning R63's Dementia care or Post Traumatic Stress Disorder. On 12/4/24 at 10:00am, V1 (Administrator) verified that R63's Dementia care and Post Traumatic Stress Disorder should be care planned and but is not. 2.…

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 monitor and prevent weight loss for one of five residents (R77) reviewed for weight loss in the sample of 33 residents. The findings include: The Dietician Referrals and Recommendations policy dated 2/2024 documented the dieticians recommendations will be communicated to the medical provider to provide appropriate interventions; review monthly weights; complete nutritional assessments on residents according to annual MDS (Minimum Data Set), high risk criteria consists of unintentional weight loss of greater than 5 percent in one month, greater than 7.5 percent in three months and greater than 10 percent in six months. The Dietician Nutritional Risk Referral policy dated 11/2012 documented the Dietary Manager and/or the Interdisciplinary team may implement nutritional intervention as deemed appropriate with Physician/designee input and approval. The Regional Dietician Consultant will follow up on the effectiveness of nutritional interventions and make…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision for a severely cognitively impaired resident identified as an elopement risk for one of three residents (R1) reviewed for elopement. This failure resulted in R1 following ancillary staff out of the facility, taking public bus transportation, and wandering throughout the city unattended for greater than three hours. This past compliance occurred on 7/6/24. Findings include: R1's Elopement Risk Assessment, dated 5/3/24, documents that R1 is at risk to elope and should be placed on the elopement risk protocol and a care plan for elopement is indicated. R1's Brief Mini Mental Status, dated 6/21/24, documents a score of 3, indicating that R1 is severely cognitively impaired. R1's current care plan documents that R1 requires the support, care and services of a long-term care facility and has been determined by community assessment to be able to access the community with supervision. This form documents that upon the outcome…

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

Based on observation, interview, and record review the facility failed to ensure the resident room floors, blinds, and a shower room toilet were kept clean and without debris. The facility also failed to ensured soiled linen was kept off the floor and removed from resident rooms for 39 of 39 residents (R1, R3, R6, R8, R11, R13, R15, R16, R22, R28, R33, R34, R40, R41, R42, R43, R45, R50, R51, R52 R53, R59, R62, R63, R65, R66, R67, R68, R69, R70, R72, R76, R77, R78, R80, R81, R82, R85, R89) reviewed for clean and homelike environment in the sample of 62. Findings include: The Housekeeping Guidelines (not dated) documents Purpose: To provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors. Standards: 6. Housekeeping personnel shall adhere to daily cleaning assignments developed so to maintain the facility in a clean and orderly manner. The Housekeeping Cleaning Schedule policy (not dated) documents Purpose: To establish a schedule which ensures the building and equipment is maintained in a clean and sanitary manner. All items may be…

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 fingernail care, facial hair grooming, and scheduled showers for 4 of 18 residents (R43, R45, R50, and R83) reviewed for ADL (Activities of Daily Living) in a sample of 62. The Certified Nursing Assistant Job Description dated 5/2/2017 documents Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare, and safety of all residents. Essential Duties and Responsibilities: Provide assistance in personal hygiene by giving bed baths, urinals, baths, back rubs, shampoos, and shaves; assisting with travel to the bathroom; helping with showers and baths. The Morning Care (A.M. Care) policy dated 1/31/18 documents Purpose: To promote comfort, cleanliness and dignity. Guidelines: Prepare water to wash, offer washcloth to wash hands. 1.On 6/24/24 at 9:55 AM, R43 was lying in his bed. R43 had long facial hairs on his chin, cheeks, and a longer mustache. R43's bilateral fingernails were long and jagged with…

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

Based on observation, interview, and record review the facility failed to ensure a call light was in reach for 3 of 18 residents (R43, R45 and R83) reviewed for call lights in a sample of 62. The Call Light policy dated 2/2/18, documents Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 6. Call bell system defects will be reported promptly to the Maintenance Department for servicing. Check room frequently until system is repaired. 1. On 6/24/25 at 9:25 AM, R45 was lying in bed with a tray of food in front of her. R45 had no string attached to the call light panel, therefore no call light was placed within R45's reach. R45 was not interviewable at this time. On 6/25/24 at 9:08 AM, R45 remained without a call light cord for her side of the room and no call light…

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 change gloves, perform hand hygiene, and properly handle soiled linens during indwelling urinary catheter/perineal care for one (R5) of one resident reviewed for indwelling urinary catheters in a sample of 62. Findings include: The facility's Urinary Catheter Care policy, dated 2/14/19, documents Purpose: To establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. Guidelines: 1. Disposable one-time use gloves shall be worn when emptying urinary drainage bags and when performing perineal care. 2. Hand hygiene shall be performed before and after touching any part of the urinary catheter drainage system. The facility's Hand Hygiene/Handwashing policy, dated 1/10/18, documents Definition: Hand Hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, or antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel) .Examples of When to Perform Hand Hygiene (Either Alcohol Based Hand…

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 nebulizer mask and nebulizer tubing was dated and stored in a bag between uses for one of one resident (R43) reviewed for respiratory care in a sample of 62. Findings include: The Oxygen and Respiratory Equipment - Changing/Cleaning policy dated 1/7/19 documents Purpose: 1. To provide guidelines to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Procedure: 1. Handheld Nebulizer (HHN) and Mask if applicable a. The handheld nebulizer should be changed weekly and PRN (as needed). b. A clean plastic bag with a zip loc or draw string. etc. (etcetera) will be provided with each new set up and will be marked with the date the set up was changed. R43's current POS (Physician Order Sheet) documents an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg(milligram)/3ml(milliliter) one vial inhale orally four times a day for seven days.…

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 apply gowns prior to providing high-contact care for gastrostomy tube for one of one resident (R43) reviewed for enhanced barrier precautions in a sample of 62. Findings include: The Enhanced Barrier Precaution policy dated 5/7/24 documents Purpose: To reduce risk of transmitting multidrug-resistant organisms (MDRO) and targeted MDRO when contact precautions do not apply for residents identified as higher risk. Guidelines: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug- resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated for resident with any of the following: Chronic Wounds and /or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical device examples include: Feeding tubes. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care…

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

Based on interview and record review the facility failed to notify the physician of medications not available for one resident (R1) of three reviewed for notification in a sample of three. Findings include: The facility's Physician/Family/Responsible Party Notification policy, dated 10/2015, documents that the facility will inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). R1's After Visit Summary, dated 3/22/24, documents to apply a Clonidine 0.2mg (Milligrams)/24-hour transdermal patch every week, start this on 3/25/24. This form documents that R1 has an allergy to Clonidine HCL, dry mouth; rebound to hypertension to the oral preparation. R1's Progress Notes, dated 3/23/24 through 3/31/24, has no documentation that V7 (R1's Primary Care Physician) was notified of R1's allergy, nor to clarify 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 ensure physician ordered medications were available for one resident (R1) of three reviewed for medications in a sample of three. Findings include: The facility's Pharmacy policy, revised 8/2020, documents that the medications and related products are received from the pharmacy on a timely manner. The facility maintains accurate records of medication order and receipt. R1's After Visit Summary, dated 3/22/24, documents to apply a Clonidine 0.2mg (Milligrams)/24 hours transdermal patch every week, start this on 3/25/24. R1's MAR (Medication Administration Record), dated 3/22/24 through 3/31/24 documents that the Clonidine 0.2mg/24-hour transdermal patch was not available. R1's Clonidine 0.2mg/24-hour transdermal patch was not signed out as being applied until 4/7/24. R1's MAR, dated 4/2/24 through 4/7/24, documents that R1's Lacosamide (anticonvulsant) 50mg was not available. R1's Pregabalin (GABA Analogue) 75mg daily, was not available 4/4/24 through 4/9/24. On 5/24/24 at 10:00am, V2 (Director of Nursing) verified that R1's…

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

Based on observation, interview, and record review the facility failed to ensure the facility was equipped with functional bathing facilities/shower rooms. This failure has the potential to affect all 90 residents residing within the facility. Findings include: The facility's Census Log dated 5-10-24 documents 90 residents reside within the facility. The facility's Preventive Maintenance and Inspections (undated) policy documents, In order to provide a safe environment for residents, employees, and visitors, a preventative maintenance program has been implemented to promote maintenance of fissures and equipment in a state of good repair and condition. Routine inspections promote safety throughout the facility and aid in keeping fixtures and equipment in good working order and operating in accordance with manufacturer's guidelines. Preventive maintenance is the care and servicing by personnel for the purpose of maintaining fixtures, equipment, and facilities in a satisfactory operating condition by providing systematic inspection, detection, and correction of incipient failures…

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 residents received showers as preferred instead of bed baths for five of six residents (R1, R3, R4, R5, R6) reviewed for accommodation of needs in the sample of sixteen. Findings include: The facility's Shower and Tub Bath policy dated 11-28-12 documents, A shower, tub bath, or bed/sponge bath will be offered according to resident's preferences two times per week or according to the resident's preferred frequency and as needed or requested. The facility's Resident Rights policy dated 8-23-17 documents, Exercising rights means that the residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. R1's BIMS (Brief Interview of Mental Status) dated 4-23-24 documents R1 is cognitively intact. R3's BIMS dated 3-12-24 documents R3 is cognitively intact. R4's BIMS dated 3-24-24 documents R4 is cognitively intact. R5's BIMS dated 3-29-24…

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

Based on observation, interview, and record review the facility failed to ensure Certified Nursing Assistant staff were licensed and trained to perform resident haircuts. These failures had the potential to affect 12 of 12 residents (R1, R5, R7-R16) reviewed for competency of staff in the sample of 16. Findings include: The Illinois Professions, Occupations, and Business Operations (225 ILCS/Illinois Compiled Statutes 410/) Barber, Cosmetology, Esthetics, Hair Braiding, and Nail Technology Act of 1985 Article I General Provisions effective dated 1-1-11Section 1-2 Public Policy states, The Department requires the practices of barbering, cosmetology, esthetics, hair braiding, and nail technology in the State of Illinois are hereby declared to affect the public health, safety and welfare and to be subject to regulation and control in the public interest. It is further declared to be a matter of public interest and concern that the professions merit and receive the confidence of the public and that only qualified persons be permitted to practice said professions in the State 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 that facility failed to staff a Licensed Administrator. This failure has the potential to affect all 85 Residents residing in the Facility. Findings include: Facility Resident Roster, dated 1/20/24, documents 85 Residents residing in the Facility. Facility Assessment Plan, dated 12/10/23, documents requirements: Corporate Leadership/Consultants and Administrative Leadership; and Administrator is a required as Assessment Contributor. On 1/20/24 at 8:45 am, V1 (Administrator in Training) stated, I am the Administrator. On 1/23/24 at 11:15 am, V1 (Administrator in Training) stated, I am the Administrator, but I do not have my license yet, but (V18) is the Administrator here at this Facility with a license. V1 then provided V18's Administrator License. During the survey, 1/20/23 through 1/24/24, V1 (Administrator in Training) was acting as the Facility Administrator and V18 was not present or available. V18's electronic mail correspondence (E-Mail) to the local State Agency, dated 1/16/24 at 9:19 am, documents, I just wanted to make the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to perform and complete discharge planning for two (R3 and R7) of three Residents reviewed for Discharge Planning in a sample of 21. Findings include: Facility Discharge Planning Guidelines Policy, dated 10/27/22, documents: Discharge planning is the process of creating an individualized discharge care plan, which is part of the comprehensive care plan. It involves the interdisciplinary team working with the resident and resident representative, if applicable, to develop interventions to meet the resident's discharge goals and needs to ensure a smooth and safe transition from the facility to the post-discharge setting; discharge planning begins at admission and is based on the resident's assessment and goals for care, desire to be discharged , and the resident/s capacity for discharge. It also includes identifying changes in the resident's condition, which may impact the discharge plan, warranting revisions to interventions; Ensure that the discharge needs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the facility Ombudsman monthly of the facility transfers and failed to provide residents and resident representatives with a written notice of transfer. This failure has the potential to affect all 82 residents currently residing in the facility. Findings Include: 1. R3's (facility) Census List documents that R3 was hospitalized on [DATE]. R3's medical record does not contain documentation of written notice to R3 or R3's resident representative, of a transfer to the hospital. 2. R5's (facility) Census List documents that R5 was hospitalized on [DATE]. R5's medical record does not contain documentation of written notice to R5 or R5's resident representative, of a transfer to the hospital. 3. R17's (facility) Census List documents that R17 was hospitalized on [DATE], 9/3/23, 10/7/23 and 11/29/23. R17's medical record does not contain documentation of written notice to R17 or R17's resident representative, of a transfer to the hospital. 4. R53'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital. This failure has the potential to affect all 82 residents currently residing in the facility. Findings include: 1. R3's (facility) Census List documents that R3 was hospitalized on [DATE]. R3's medical record does not contain documentation of written notice to R3 or R3's resident representative, of the facility bed hold policy. 2. R5's (facility) Census List documents that R5 was hospitalized on [DATE]. R5's medical record does not contain documentation of written notice to R5 or R5's resident representative, of the facility bed hold policy. 3. R17's (facility) Census List documents that R17 was hospitalized on [DATE], 9/3/23, 10/7/23 and 11/29/23. R17's medical record does not contain documentation of written notice to R17 or R17's resident representative, of the facility bed hold policy. 4. R53's (facility) Census List documents that R53 was hospitalized 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.

Based on observation, interview and record review, the facility failed to have sufficient dietary employees to serve the residents meals in the facility at the scheduled time. This has the potential to affect all 82 residents living in the facility. The findings include: The Facility Assessment, last reviewed on 5/2023, states, Dietary: Food Service Staff - Seven Dietary Workers per day. The Dietary work schedule for December, shows that for the first 10 days, only one day was fully staffed. One day with only two staff; four days with only three staff; two days with only four staff; two days with only five staff. On 12/10/23 at 10:15 AM, V7 (Cook) was working alone in the kitchen, currently washing dishes in the dish machine. V7 stated, I'm working by myself again. I've only been here for seven days and have worked the majority of the days by myself or with one other person. A couple of Certified Nursing Assistants came into the kitchen this morning to help me cook and get breakfast out. If they hadn't helped me, I don't know when I would have gotten the breakfast ready. At 10:30…

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.

Based on observation, interview and record review the facility failed to serve the correct amount of food according to the facility's written menu. This has the potential to affect all 82 residents living in the facility. The findings include: The Document, Diet Summary, dated 2022, states, With the proper selection of foods, the Regular Diet planned utilizing the menu planning components per the Guidelines for Menu Planning, meets the current Dietary Reference Intakes/Recommended Dietary Allowances/Adequate Intakes, Food and Nutrition board, Institute of Medicine, National Academy of Science 2011. The Regular Diet is consistent in portions and therefore is appropriate for use for most individuals with diabetes and individualized nutrition approaches for older adults in health care communities. The minimum Daily Menu Components employed in menu planning include: 6 ounces of Edible Protein; 2 Servings of Fruit or More; 3 Servings of Vegetables or more; 6 servings of Grains or more; 2 cups of Milk. The Document, Menu Diet Spreadsheets/Portion Serving Communication Tool, dated 2020,…

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 consistently record steam table food temperatures at each meal daily. The facility failed follow/attain recommendations for heating food in a microwave oven. The facility also failed provide residents with meals that were warm and palatable. This has the potential to affect all 82 residents living in the facility. The findings include: The last 30 days were reviewed on the Daily Data Sheet for Food Temperatures. Of the 30 days, only eleven sheets had meal temperatures logged: For 20 days there were no temperature sheets. For two days there were no temperatures were logged for any meal, but the sheets were provided. For four days breakfast and luncheon temperatures were logged. For two days temperatures were partially logged; and only two days the meal temperatures were logged for all three meals. On 12/10/23 at 12:30 PM, V7 (Cook) was asked when she would be ready do take the steam table food temperatures. V7 stated, No one told me that I had to take temperatures! V7 began to take the food temperatures. When…

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

Based on observation, interview and record review, the facility failed to prepare enough food at meals to provide all the food items from the menu to all the residents. The facility substituted food items or omitted them. The facility failed to have a substitution log of foods that have been substituted from the menu. The facility failed to provide the residents with choices which included all the food items on the Always Available Menu. This failure has the potential to affect all 82 residents living at the facility. The findings include: The document, Menu Substitutions or Changes and Approval, dated 2020, states, All substitutions, whether a one-time substitution or a permanent menu change are recorded using a community specific document or a menu substitution form. The registered dietitian periodically reviews the documented menu substitutions or menu changes for nutritional equivalency and appropriateness. The registered dietitian is available for questions or clarifications regarding any menu substitutes or menu changes as needed. A log of all substitutions is kept on file,…

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 the correct, allowed food to the residents on a Low Fiber Diet and the Mechanical Soft Diet. This failure has the potential to affect 12 of 12 residents (R2, R4, R11, R18, R20, R23, R24, R28, R49, R51, R57, and R60) in a sample of 43. The findings include: The Low Fiber Diet, dated 2022, states, The Low Fiber Diet is designed to reduce the amount of fecal bulk and intestinal activity. Canned or cooked vegetables are used in place of raw that are without skins or seeds. Vegetables Not Allowed: Corn, Creamed Corn. The Mechanical Soft Diet, dated 2022, states, The Dental Soft (Mechanical Soft) Diet is for individuals with limited or difficulty in chewing regular consistency foods. The diet excludes hard to chew foods. Foods should be moist and fork tender. Meat: Meat is ground or chopped into one half inch or less size pieces and should be mixed or served with gravy. Grains: All whole grain and enriched breads, pancakes, muffins, rolls and crackers without hard crust or crust is removed. Vegetables: cooked…

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 resident to resident physical and verbal abuse for 3 of 9 residents (R15, R37, R65) reviewed for Abuse in the sampled of 43. Findings include: The facility's Abuse Prevention and Reporting policy, dated 4/29/22, documents The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. On 12/12/23 at 10:15 AM, R65 was in his room sitting in a wheelchair. R65 stated A couple weeks ago I had an altercation with (R37). (R37) has told me he's gonna kick my a and that he will kill me. (R37)…

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

Based on interview and record review, the facility failed to report an incident of resident-to-resident physical abuse to the state agency and to the police for 3 of 9 residents (R15, R37, R65) reviewed for abuse in the sample of 42. Findings include: The facility's Abuse Prevention and Reporting policy, dated 4/29/22, documents The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This policy also documents External Reporting. Initial Reporting of Allegations: When the allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. (The State Agency) shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property had been reported and is being investigated. The report shall include the following information, if known at the time of the report. All alleged violations involving abuse,…

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

Based on interview and record review, the facility failed to investigate and prevent further occurrence of an incident of resident-to-resident physical abuse for 3 of 9 residents (R15, R37, R65) reviewed for abuse in the sample of 42. Findings include: The facility's Abuse Prevention and Reporting policy, dated 4/29/22, documents The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This policy also documents Reports should be documented and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act as administrator in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. On 12/12/23 at 10:15 AM, R65 was in his room sitting in a wheelchair. R65 stated A couple weeks ago I had an altercation with (R37). (R37) has told me he's gonna (sic)…

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 follow a resident's advanced directive wishes in an emergency for one of one resident (R47) reviewed for Advanced Directives in the sample of 43. Findings include: The facility's Advance Directives policy, dated [DATE], documents Purpose: To ensure that all residents and/or resident representatives are informed concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. Guidelines: At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law. Copies of the resident's Advanced Directive shall be made and maintained in the resident's clinical record and financial folder. Advanced Directives shall be included in the resident's plan of care and will be reviewed during the care plan meeting with resident and/or the resident's legal representative when present. R47's Practitioner Order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's medical record were accurate and without discrepancies for 1 of 18 residents (R47) reviewed for medical records in the sample of 43. Findings include: The facility's (undated) Medical Records policy documents Medical records must be complete, accurately documented, readily accessible, and systematically organized. R47's Practitioner Order for Life-Sustaining Treatment (POLST), dated [DATE] and signed by R47 and V25 (R47's Physician) documents R47 chooses No CPR (Cardiopulmonary Resuscitation)- Do Not attempt Resuscitation (DNR) in the event of a medical emergency. R47's Nursing Progress Notes, dated [DATE] at 8:45 AM and signed by V22 (Licensed Practical Nurse) documents Resident (R47) noted on the floor, prone on the fall mat, unresponsive. This nurse checked the code status in the computer, resident was noted to be a Full Code. This nurse immediately grabbed the crash cart, called a code, and initiated CPR. Another nurse assisted…

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

Based on observation and interview the facility failed to provide a clean and functioning sink for three residents (R5, R6 and R7) of three residents reviewed for functioning sinks in their rooms. Findings Include: On 12/28/23 at 1:30 PM the sink in room AA had rust colored water when water was run. The color did not clear when water was run for more than 30 seconds. On 12/28/23 at 1:31 PM V18 (Maintenance Director) stated I didn't know there was problem in here. I will address it today. On 12/28/23 R7 (Room AA occupant) stated I don't drink the water out of my room, it is gross. On 12/28/23 at 1:35 PM the sink in Room BB only ran lukewarm water on one side of the sink. On 12/28/23 V18 (Maintenance Director) stated Someone completely removed the cold-water valve; I am not sure why. On 12/28/23 R5 (Room CC occupant) refused to answer any questions. On 12/28/23 R6 (Room CC occupant) stated The sink has been like that for months; I go to the shower room to use that sink. On 12/28/23 at 10:00 AM V1 (Administrator) stated We have some environmental issues, I just hired (V18 Maintenance…

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 provide toenail care for one resident (R2) of three residents reviewed for foot care. Findings Include: R2's Podiatry Consent dated 4/5/23 documents (This Facility) offers monthly podiatry visits. I Accept was marked and signed by R2. On 12/28/23 at 1:00 PM R2's feet were very dry and misshapen. R2's left foot second toenail was thick and yellow and grown out enough to curl completely back on itself. R2's other toenails were thick and yellow. R2 stated that staff at the hospital had cut her toenails as best as they could. R2 stated she could not recall the last time her toenails were cut other than recently at the hospital. R2's Medical Record did not contain any documentation of any attempts to clip R2's toenails or to have R2 see the Podiatrist on his past two visits. On 12/28/23 at 1:10 PM V3 (Assistant Director of Nursing) stated (R2)'s nails are way over grown, she needs to be seen by the podiatrist.

Based on interview and record review, the facility failed to document the administration of the physician ordered medications for 1 of 3 residents (R2) reviewed for medication administration in the sample of 6. Findings include: R2's Medication Administration Record (MAR) dated 10/1/23 - 10/31/23 documents the following medications were not signed as given Lidocaine Pain Patch 4% (percent) on 10/24/23 at 8:00 AM, Budesonide Aerosol (2 puffs) on 10/15 and 10/24/23 at 4:00 PM, Carvedilol 25 milligram/mg tablet on 10/15 and 10/24/23 at 4:00 PM, Famotidine 20 mg tablet on 10/15 and 10/24/23 at 4:00 PM, and Guaifenesin 200 mg tablet (give 600 mg) on 10/15 and 10/24/23 at 4:00 PM. On 10/28/23 at 10:17 AM, V3 (Assistant Director of Nursing) stated that it does not look like some of the medications were administered to R2. V3 does not know why they were not signed off the MAR/Medication Administration Record. V3 also stated I can't say if (R2) got his medication or not, but I know if it is not signed off the MAR it is considered as not given. There is definitely a problem that will require…

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 were not wearing/using cell phone devices during their shift or when providing cares and were treating residents with respect. This has the potential to affect all 81 residents residing in the facility. Findings include: The facility's employee handbook documents Telephone Calls and Telephone Cameras: Use of personal cell phones, including photographing and texting during business hours, should only be done in designated break rooms. The state Ombudsman resident rights requirements for long term care facilities documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. 10/4/23 at 12:59 PM, V31 (Housekeeping) was in a resident care hallway outside of R3's bedroom with V31's housekeeping cart. V31 was wearing wireless earbuds and talking on a cellular/cell phone. At this time, V31 verified V31 was using V31's cellular phone in a resident care area. On 10/4/23 at 12:30 PM, R2 stated, The staff are on their phones all 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 follow posted menu items. This failure has the potential to affect all 81 residents residing in the facility. Findings include: On 10/3/23 at 9:00 AM, there are frozen turkey roasts observed sitting on one of the counters in the kitchen. V3 (Dietary Manager/DM), stated Those just came in. As you can see, they come in frozen and have to thaw out. Unfortunately, they won't thaw out before lunch so we're going to swap today and tomorrows lunch. We'll serve the tacos today and the roast turkey tomorrow. On 10/3/23 at 11:52 AM, R7 stated Can you figure out why the facility never follows the menu? Well, we're supposed to have an egg casserole for breakfast, but they never serve it. They're also always switching the lunch items. We never know what we're going to have for meals until it's served. The facility's spring, summer, fall, and winter menus document a breakfast casserole and an egg and cheese casserole to be served for breakfast twice a week. On 10/3/23 at 12:50 PM, V3 verified the breakfast and egg, and…

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

Based on observation, interview and record review, the facility failed to discard expired milk stored in the cooler. This failure has the potential to affect all 81 residents residing in the facility. Findings include: The facility's Guideline to Food Storage dated 2020 documents 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. See Date Marking Guidelines in this section for exceptions to dating individual dry storage food items. b. Rotate products so the oldest are used first. Staff shall be instructed to use products with the earliest expiration date before those with a later expiration date. c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. On 10/3/23 at 8:56 AM, a walk-through of the kitchen was conducted with V3 (Dietary Manager/DM). In the kitchen's walk-in refrigerator, there were several milk containers stacked on top 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 protect a resident's right to not be recorded or photographed without consent for four residents (R10, R11, R13 and R14) out of eight residents reviewed for resident's rights in a sample of 14. Findings Include: The facility's Resident Rights policy dated 8/23/17 documents To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. Guidelines: Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: Exercise his or her rights. Be informed about what rights and responsibilities he or she has. If he or she wishes, have the facility manage his personal funds. Choose a physician and treatment and participate in decisions and care planning. Privacy and confidentiality. V21's (Medical Director)…

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

Based on observation, interview and record review, the facility failed to provide a means for residents to dry their hands after washing them for five residents (R1, R2, R3, R7 and R9) out of nine residents reviewed for supplies in a sample of 14. Findings include: 1. On 10/3/23 at 11:44 AM, R9's paper towel dispenser was empty. R9 stated I couldn't tell you the last time they filled that. I honestly don't know. I just wipe my hands on my shirt. 2. On 10/3/23 at 11:52 AM, R7's paper towel dispenser was empty. R7 stated There's never any paper towels in there. How do they expect us to wash our hands if there's never any paper towels? Upon observation of R7's room, there were no other items in R7's room to dry his hands. R7 stated I used to have a towel in here that I could dry my hands off with, but housekeeping took it. That's what I'm saying. There's nothing in here to dry my hands. 3. On 10/3/23 at 1:40 PM, R1's paper towel dispenser was empty. R1 stated They haven't had paper towels in that thing for weeks. Look at the sink over there. You tell me how we're supposed to wash our…

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 showers to a resident who required assistance with bathing for one of three residents (R6) reviewed for activities of daily living in the sample of 14. Findings include: The facility's Bathing - Shower and Tub Bath Policy revised 1/31/18 states, Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference two times per week or according to the resident's preferred frequency and as needed or requested. The facility's Certified Nursing Assistant Job Description dated 5/2/17 states, The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. This same Job Description states, Provide assistance in personal hygiene by giving bedpans, urinals, baths, backrubs, shampoos, and shaves; assisting with travel…

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 administer medications as ordered by the physician, provide treatments as ordered by the physician and failed to process a physician's order for one resident (R1) out of four residents reviewed for medication administration in a sample of 14. Findings include: The facility's Medication Administration General Guidelines policy undated documents Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility ' s medication distribution system (procurement, storage, handling and administration). Administration: 1. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. 2. Medications are administered in accordance with written orders of the prescriber. The facility's Physician Orders-Entering and Processing policy dated 1/31/18…

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 prescriber correctly transcribed an order for a resident's anti-seizure medications; failed to obtain follow-up physician orders after a resident's documented refusal of anti-seizure medications, and failed to ensure nurses accurately documented when an anti-seizure medication was given for one of four residents (R6) reviewed for medications in the sample of 14. Findings include: The facility's Medication Administration General Guidelines undated documents medications are administered as prescribed in accordance with good nursing principles and practices. Preparation: 6. Five Rights-right resident, right drug, right dose, right route and right time, are applied for each medication being administered. 7. The Medication Administration Record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label.…

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 physician ordered laboratory tests for one of four residents (R6) reviewed for physician orders in the sample of 14. Findings include: The facility's Physician Notification of Laboratory/ Radiology/Diagnostic Results Policy revised 3/14/18 states, Purpose: To assure physician ordered diagnostic test are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care. Guidelines: A licensed nurse is responsible for assuring the laboratory is notified of physician's orders for testing. This same policy states, A nurse is responsible for monitoring the receipt of test results. Test results should be reported to the physician or other practitioner who ordered them. R6's current Care Plan documents R6 is at risk for seizures related to a history of epilepsy. This same Care Plan states, Obtain labs/diagnostics as ordered and notify MD (Medical Doctor) of results. R6's Order Summary Report dated 7/1/23-10/31/23 documents the following:…

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 allow a resident access to the hospital for one resident (R1) out of three residents reviewed for access to medical care in a sample of three. Findings include: The facility's Resident Rights policy dated 1/4/19 documents Notice of resident rights will be provided upon admission to the facility. These rights include the resident's right to: Exercise his or her rights. Choose a physician and treatment and participate in decisions and care planning .Exercising rights means that residents have autonomy and choice, to maximum extent possible., about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The facility will not hamper, compel, treat, differentially, or retaliate against a resident for exercising his/her rights. Facility practices designed to support and encourage resident participation in meeting care planning goals and documented in the resident assessment and care plan are not interference or coercion. R1'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 address a resident's report of pain, address a resident's report of possible urinary tract infection (UTI), failed to notify the physician of a change in condition, and transfer a resident per the resident's request to the hospital for one resident (R1) out of three residents reviewed for change in condition in a sample of three. Findings include: The facility's Physician-Family Notification - Change in Condition policy dated 10/1/15 documents To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient and effective manner. The facility will inform the resident, consult with the resident's legal representative or an interested family member when there is: (B) a significant change in the resident's physical, mental or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.) Clinical complications are such things as development of a stage 2…

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.