Sunny Acres Nursing Home

Based on interview and record review the facility failed to implement their Abuse Policy to immediately report an allegation of abuse to the Administrator and the State Agency for one of three residents (R4) reviewed for Abuse in the sample of 17.Findings include:The facility's Abuse Prohibition Policy, dated 3/15/2018, documents, A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. A facility administrator who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter by telephone and in writing to the resident's representative. The administrator shall provide the Illinois Department of Public Health (IDPH) with initial notice of the alleged abuse, neglect, or incident of unknown origin by telefaxing the Department a copy of a report of the incident completed immediately after the incident becomes known. R8's Compliment/Complaint form dated 7/11/25 and signed by V3 (Speech Language Pathologist/SLP) documents, Reported by (R8)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent resident injury during transfer in a wheelchair, failed to investigate the cause of the injury, and failed to develop interventions after the injury to prevent future injuries for one of three residents (R4) reviewed for accidents in the sample of 17.Findings include:The facility's Occurrence Reporting to (local State Agency) Policy and Procedure dated 10/3/11 documents, The facility shall maintain a file of all written reports of each incident and accident affecting a resident that is not the expected outcome of a resident's condition or disease process. Procedure: Provide immediate care to the resident. Initiate the appropriate monitoring of the resident. Notify the physician and family of the occurrence. If the occurrence requires it, complete a Risk Watch Occurrence Report form. Staff will document specific information relating to the occurrence including the exact description of facts surrounding the occurrence. Include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report allegations of staff to resident physical abuse to the Administrator/Abuse Coordinator for one (R1) of four residents reviewed for abuse in a sample of four. Findings include: The facility's Abuse Prohibition Policy, Revised 3/15/18, documents: All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. Reporting - Allegations of Abuse and Neglect: 1. A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12…

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 properly cleanse a food thermometer before use and between foods when checking steam table food temperatures, ensure a hairnet was worn correctly in the kitchen, label and date open food items in refrigerators and dry food storage areas, ensure freezers contained internal thermometers and thermometers in working condition, use dishwasher temperature testing strips that reflect the required dish surface temperature, check the surface temperature daily to ensure dishes reach the required temperature during the rinse cycle of a high temperature sanitation dish machine, and ensure juice and coffee dispensers in the main dining room were clean and free from buildup and slime. These failures have the potential to affect all 85 residents residing in the facility. Findings include: The facility's Food and Nutrition Services Manager Job Description (undated), documents Job Summary: Production and service of high-quality meals; organize, supervise, and train dietary employees; purchase food and supplies; provide a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow a physician's order to reduce an anti-psychotic medication for one resident (R17) and failed to document behaviors and diagnoses to justify the use of anti-psychotic medications for four of six residents (R5, R10, R17, R64) reviewed for anti-psychotic drug use with the diagnosis of Dementia in the sample of 35. Findings include: The Psychotropic Medication policy dated 11/28/17 documents, Intent: Residents are free from unnecessary psychotropic medication use. Psychotropic medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but not limited to 1) Antianxiety 2) Antidepressant 3) Antipsychotic. These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other…

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

Based on Observation, Interview, and Record Review the facility failed to complete hand hygiene between residents receiving medications, follow Enhanced Barrier Precautions during direct resident cares, and dispose of soiled washcloths in a sanitary manner for five of 25 residents (R6, R27,R30, R39, R47) reviewed for infection control in the sample of 35. Findings include: The facility's Medication Administration policy, dated 1/11/10, documents Objective: To provide accuracy during medication pass to assure quality for residents. Procedure: Wash hands according to facility protocol. Wash prior to medication pass, after administering eye preparations and after removing gloves and when hands become soiled. The Facility's Enhanced Barrier Precautions Protocol Policy, revised 4/8/24, documents, Enhanced Barrier Precautions expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to evaluate the use of physical restraints and prevent the use of physical restraints to prevent a resident (R5) from self-transferring out of bed for one of one resident (R5) reviewed for physical restraints in the sample of 35. Findings include: The facility's Abuse Prohibition Policy, dated 3/15/2018, documents Abuse and Neglect Prohibited: 1. All residents have the right to be free of from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. This includes but is not limited to freedom from corporal punishment, and involuntary seclusion and physical or chemical restraints not required to treat the resident's symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time with ongoing re-evaluation and documentation of the need for restraints. The facility's Restraint Program Policy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to request a PASRR (Pre-admission Screening and Resident Review) for one of one resident (R10) reviewed for PASRR in a sample of 35. Findings Include: R10's admission Record documents that R10 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Vascular Dementia, Unspecified Severity, With Other Behavioral Disturbance, Major Depressive Disorder, and Anxiety Disorder. R10's MDS (Minimum Data Set) Assessment, dated 1/30/25, documents R10 is cognitively intact, has no hallucinations or delusions, has no physical/verbal/or other behaviors directed at others, and does not reject care. R10's Medical Record does not include evidence of the facility obtaining R10's PASRR Level I prior to admission to the facility. On 3/3/25 at 2:24 PM, V1/Administrator stated the facility had not obtained a level I PASRR for R10.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to refer a resident to the PASRR (Preadmission Screening and Resident Review) State Agency to obtain a Level II PASRR after being diagnosed with a Mental Illness for one of one resident (R10) reviewed for Mental Illness in the sample of 35. Findings Include: R10's admission Record documents that R10 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Major Depressive Disorder and Anxiety Disorder. R10's Diagnoses Listing documents R10 was diagnosed with Delusional Disorder (a serious mental illness) on 11/24/23. R10's current Physician Orders documents R10 has an order for Quetiapine (Antipsychotic medication) 12.5 mg (milligrams) by mouth at bedtime related to Delusional Disorders. R10's Medical Record does not include evidence of the facility obtaining R10's PASRR Level II after being diagnosed with Delusional Disorder. On 3/3/25 at 2:24 PM, V1/Administrator stated the facility does not have a level II PASRR for R10.…

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 develop a Care Plan for oxygen use for one of 18 residents (R185) reviewed for care plans in the sample of 35. Findings include: The Resident Care policy dated 11/2017 documents A Comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals, and address the residents medical, physical, mental, and psychosocial needs, while honoring resident rights to choose. This care plan shall include goals, measurable objectives, and interventions to meet identified resident needs. The comprehensive care plan may be completed in conjunction with the admission MDS (Minimum Data Set), or within the first 48 hours of stay. If completed as replacement for the baseline care plan, the comprehensive care plan must be modified based on information gathered during completion of the admission MDS (Minimum Data Set) assessment, as well as ancillary assessments and observations. The modified Comprehensive care plan must be completed by day 21 of the residents stay. All plans of care must 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.

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 fingernails (R36's) were kept trimmed and cleaned and ensure a resident (R32) received a shower or bath at least once a week for two of two residents (R32 and R36) reviewed for ADLs (Activities of Daily Living) in the sample of 35. Findings include: 1. The facility's Nail Care Policy dated 9-8-2005 documents, Nails and feet need special attention to prevent infection, injury, and odors. Long or broken nails may scratch the skin or snag clothing. Routine nail care may include cleaning, filing, or cutting. R36's current Care Plan documents R36 is at risk for an ADL self-care deficit related to the diagnosis of Multiple Sclerosis, Osteoporosis, and Hypertension. On 03/03/25 at 10:36 AM and 03/04/25 at 9:25 AM R36 was sitting in her room in a wheelchair. During these times, all R36's fingernails were long, jagged, and had brown matter underneath. R36 stated, I cannot remember last time my nails were clipped and cleaned. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow a physician ordered treatment for one of one resident (R32) reviewed for skin alterations in the sample of 35. Findings include: The Wound Policy dated 3/28/24 documents It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Procedure: Wound- an area of skin impairment or damage which has been manifested or resulted other than by pressure for which treatment and/or observation is provided until such time as that area has resolved by healing. Treatment continues per physician's orders until the wound and/or ulcer is healed. R32's Face Sheet documents R32 is a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses which included Acute and Chronic Diastolic Congestive Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Muscle Weakness, need for Assistance with Personal…

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

Based on observation, interview, and record review the facility failed to develop and implement services to maintain and/or improve range of motion limitations and failed to develop a care plan to address limitations in range of motion for two of two residents (R3 and R36) reviewed for limitations in range of motion in the sample of 35. Findings include: 1. R3's MDS (Minimum Data Set) Assessments dated 1-3-25 and 10-4-24 document R3 is cognitively intact, has functional limitations in range of motion to both sides of the lower extremities, and does not receive passive or active range of motion restorative programs. R3's current Physician's Order Sheets document R3 has the diagnosis of Muscle Weakness. R3's Contracture Risk Evaluation dated 1-3-25 documents R3 is at high risk of developing contractures. R3's current Care Plan does not include a plan of care to address R3's limitations in range of motion. On 3-3-25 at 10:18 AM R3 was sitting in a wheelchair with her legs elevated. R3 stated she cannot move her legs on her own and staff do not do range of motion exercises with her. 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 observation, interview, and record review the facility failed to provide adequate supervision to prevent falls for one of one resident (R5) reviewed for falls in the sample of 35. Findings include: The facility's Fall Assessment and Management Policy, dated 6/2024, documents Policy: It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facility an interdisciplinary approach for care planning to appropriately monitor, assess, and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. R5's MDS (Minimum Data Set) assessment dated [DATE] documents R5 is severely cognitively impaired. R5's Fall Investigations dated 10/15/24 to 1/13/25 document R5 has had six falls out of bed during this timeframe with three of these falls resulting in either bruising or skin tears. On 3/3/25 at 11:43 AM R5 was lying in bed with her eyes open. R5 was unable to answer questions appropriately. A perimeter defining…

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 properly keep the catheter bag off the floor for one resident (R79) and failed to change gloves, perform hand hygiene, and perform indwelling urinary catheter care per facility policy for one resident (R39) for two of three residents (R39 and R79) reviewed for urinary catheters in the sample of in the sample of 35. Findings include: The facility's Catheter Care-Female, dated 8/1/05, states To cleanse the meatus and adjacent catheter. Cleanse area of insertion of catheter into meatus using a clean washcloth prepared with soap and water or perineal care cleanser. Cleanse downward from top to bottom on one side, and then repeat on the other side using a clean washcloth. Cleanse catheter tubing one and a half to two inches down from insertion site. Rinse well with clean cloths, following same procedure as for washing. Dry with a clean towel. The Urinary Catheter Insertion Competency- Key (un-dated) documents Catheter bag must be placed so that…

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 date oxygen tubing and a humidifier bottle for one of one resident (R185) reviewed for oxygen in the sample of 35. Findings include: The Oxygen Administration policy dated 1/28/25 documents To administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Procedure 12. Nasal cannulas, oxygen tubing, humidifiers and reservoirs will be tagged with date and initials of date changed. 14. Guidelines for changing respiratory equipment will be as follows: a. Oxygen tubing weekly. b. Humidifier bottles weekly. R185's Physicians Orders printed 3/4/25, documents Oxygen at two liters as needed to keep oxygen saturation above 91 percent. Order date 2/3/25. On 3/3/25 at 10:42 AM, R185 was lying in bed sleeping. R185's oxygen tubing and humidifier bottle were not labeled with the date or initials. On 3/3/25 at 11:28 AM, V4/Registered Nurse/ verified R185's oxygen tubing and humidifier bottle were not labeled with the date or initials.

Based on interview, and record review the facility failed to ensure a Physician was available for emergency calls related to changes in condition for one (R1) out of six residents reviewed for physician services in the total sample of six. Findings include: The facilities Resident Care Policy and Procedure revised 4/2019 documents it is the responsibility of each nurse to notify the physician of a significant change in condition before the end of their shift. If the nurse is unable to contact the physician, the nurse may use judgement to send resident to the hospital for evaluation and treatment. R1's Nurse Progress Note dated 12/28/24 at 9:18 PM, documents R1 had a rash covering R1's body, brown mucous and brown discharge was coming from R1's vagina, and R1 had not urinated in her indwelling catheter for two days. The same Nurse Progress note documents R1's urine culture obtained 12/23/24 contained ESBL (Extended-Spectrum Beta-Lactamase an antibiotic resistant urinary tract infection) and E Coli (Escherichia coli bacteria that is a common cause of UTI). R1's electronic medical…

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

Based on interview and record review, the facility failed to obtain a physician ordered urinalysis result timely for one (R1) of four residents reviewed for laboratory services in a total sample of six. Findings include: The Facilities Physician Orders policy revised 5/2022 documents if for any reason, a physician's order cannot be followed, the physician shall be notified, and notification shall be documented in the medical record. R1's Nurse Progress Notes dated 1/9/2025 at 1:06 PM, documents that R1's urinary output was 75 milliliters and urine is thick with foul smell. V9 informed through fax, awaiting reply. R1's Physician Orders dated 1/9/25 contains an order for a urinalysis to be completed. On 1/16/25 at 12:31 PM, V3 Licensed Practical Nurse stated V3 worked on 1/9/25 and received the order for R1's urinalysis on 1/9/25 because R1 was having decreased urinary output. V3 stated she didn't obtain R1's urinalysis on 1/9/25 because she didn't have time and she passed it on to the oncoming nurse. V3 further stated she returned to work on 1/13/25 and R1's urinalysis was still in…

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

Based on record review and interview the facility failed to provide night time snacks. This failure has the potential to affect all residents in the facility who receive nutrition in the form of food. Findings Include: The Facility's undated Menus and Meal Service documents Snacks are available between meals. Evening (HS) snacks will be available to all residents. On 12/7/23 at 10:00 AM during resident council meeting R4,R35,R49,R55 and R62 all stated there were no snacks passed at bedtime. On 12/7/23 at 10:05 AM R4 stated I would like to have a snack at bed time. It depends on who is working whether or not I can get one. On 12/7/23 at 10:15 AM R35 stated I think snacks are available if we want them. But we have to go find them. I would like them to be offered to me, sometimes I am already in bed and would like a snack. On 12/7/23 at 11:00 AM V7 (Registered Nurse) stated I work some second shifts and I have never seen snacks for passing at night or any list of who gets a snack or who wants one. On 12/7/23 at 11:05 AM V 14 (Dietary Manager) stated We fill the hydration carts and we…

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

Based on record review, interview and observation the facility failed to use Personal Protective Equipment appropriately during a COVID outbreak. This failure has the potential to affect all 79 residents who currently reside in the facility. Findings Include: The Facility's COVID-19 Testing and Response Plan dated 8/29/23 documents This facility recognizes that residents living in a congregate setting are at high risk of being affected by SARS-CoV-2 (COVID-19). Risk factors associated with living in a congregate setting and characteristics of the populations served (often older adults with chronic medical conditions) can result in more severe disease from COVID-19. Staff, family members, visitors & any person(s) who are exposed to communicable disease may represent a clinical safety risk as well. The following protocol is for the purpose of protecting the well-being of any individual including, but not limited to residents, staff, family members, visitors and any person(s), considering the COVID-19 emergence in the United States. This protocol enables the facility to prevent and/or…

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 refer and obtain a level two PASARR (Preadmission screening and Resident Review) after a new diagnosis of Schizophrenia was identified for one resident (R18) of two residents reviewed for a level two PASARR in a sample of 45. Findings include: R18's Interagency Certification of Screening Results dated and signed 6-21-21 documents a negative level one pre-screen. R18's admission Record documents R18 was admitted to the facility on [DATE]. This same form documents R18 has a diagnosis of Schizophrenia with an onset date of 09-20-2022. On 12/6/2023 at 2:03 PM, V4 Regional Nurse Consultant confirmed no level two PASARR was obtained since R18's new diagnosis of Schizophrenia and should have been.

Based on interview and record the facility failed to develop a comprehensive care plan for one (R75) of 19 residents reviewed for care planning in the sample of 45. Findings include: The facility's Resident Care Policy and Procedure Policy dated 11/2017 documents, Subject: Care Plan Process. Policy and Procedure: Comprehensive Care Plan: A Comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental and goals, measurable objectives, and interventions to meet identified resident needs. The comprehensive care plan may be completed in conjunction with admission MDS (Minimum Data Set), or within the first 48 hours of stay. If completed as a replacement for the baseline care plan, the comprehensive care plan must be modified based on information gathered during completion of the admission MDS assessment, as well as ancillary assessments and observations. The modified Comprehensive care plan must be completed by day 21 of the residents stay. The facility's Resident Care Policy…

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 report, assess and provide treatment for a new pressure ulcer for one (R56) of four residents reviewed for pressure ulcers in the sample of 45. Findings include: The facility's Wound and Ulcer Policy and Procedure, revised 1/20/2018, documents It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. This policy defines: Pressure Ulcer - A pressure ulcer is localized injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Stage I - Non-blanchable erythema - intact skin with nonblanchable redness of a localized area usually over a boney prominence. Darkly pigmented skin may not have visible blanching, color may differ from the surrounding area. Stage II - Partial Thickness Skin Loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed (without…

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 a Physician's Order for the use of Oxygen for one resident (R53) of 3 reviewed for oxygen in a total sample of 45. Findings Include: The Facility's Oxygen Administration dated 5/1/2017 documents the objective of the policy is to administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. The Facility's Oxygen Administration policy documents Oxygen may not be dispensed without a physician's order. On 12/5/23 at 10:15 AM and throughout the survey R53 had oxygen on at 4 liters per minute via nasal cannula. R53 stated I've had oxygen for years. R53's Physician Order Sheet for December 2023 does not include an order for any oxygen for R53. On 12/7/23 at 11:30 AM V1 (Administrator) confirmed that R53 did not have an order for oxygen. She (R53) should have an order for the oxygen.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an appropriate indication for the use of an antipsychotic medication, document and care plan targeted behaviors to warrant the use of an antipsychotic medication, and perform GDR (Gradual Dose Reductions) for two of five residents (R18 and R32) reviewed for antipsychotics in the sample of 45. Findings include: The facility's Psychotropic Medication policy 11-28-17 documents, Intent: Residents are free from unnecessary psychotropic medication use. Psychotropic medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but not limited to 1) Antianxiety 2) Antidepressant 3) Antipsychotic 4) Hypnotic. These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other…

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

Based on interview and record review, the facility failed to follow their protocol for monitoring residents after a head injury for one (R1) of three residents reviewed for monitoring in a sample of three. Finding include: R1's progress note dated 9-29-23 at 7:20 pm documents R1 was found on the floor in his room with a scratch on his forehead and ear. E3 RN/Registered Nurse notified R1's POA/Power of Attorney and physician who agreed the facility would monitor R1's condition and send him to the hospital if anything changed. R1's progress notes dated 9-30-23 at 11:50 am document R1 had no pupil construction reaction to bilateral eyes. R1's physician sent R1 to the hospital for evaluation. R1's hospital record document R1 was admitted with a bilateral subdural hematoma requiring surgery to repair. The facility's Head Injuries policy dated 2-27-12 documents In the event that a resident receives a head injury, the resident should be assessed and the resident monitored for the following: severe headache vomiting, resident becomes very sleepy and difficult to arouse, seizures, weakness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was offered and assisted with a shower at least one time per week for one of one resident (R41) in the sample of 35. Findings include: On 1/31/23 at 10:45 a.m., R41's room had a strong urine odor. On 2/2/23 at 10:24 a.m., R41 had greasy hair that appeared wet. R41's room had a strong urine odor. R41's Minimum Data Set (MDS) assessment dated [DATE], documents R41 is cognitively intact with a Brief Interview for Mental Status score of fifteen out of fifteen. This same MDS documents R41 requires extensive assistance of one staff for personal hygiene and bathing. R41's Skin Monitoring/Shower Sheet form documents R41 received showers on the following dates: 1/8/23, 1/18/23, 1/22/23. On 2/2/23 at 10:30 am., R41 stated she has not been offered/assisted with a shower since 1/22/23. R41 stated her scheduled shower days are Wednesday and Saturday. R41 stated she is not able to shower without staff assistance. On 2/2/23 at 1:10…

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 Practitioner Order for Life-Sustaining Treatment (POLST) was signed by the Physician for one of twenty four residents (R384) reviewed for advance directives in the sample of 35. Findings include: The facility's Advance Directive Policy, dated 11/2022, documents Residents will be afforded the opportunity upon admission to the facility to submit any Advance Directive regarding their care in this facility, thereby informing the facility of each resident's desires regarding medical decision making and end of life care. Advance Directives include but are not limited to: Power of Attorney for Health Care, Living Will, IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life-Sustaining Treatment (POLST), Medically Administered Nutrition including feeding tubes. This same policy documents The IDPH Practitioner Order for Life-Sustaining Treatment (POLST) is an individual's signed and dated document that reflects an…

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 services to maintain and/or improve range of motion limitations for three of six residents (R39, R58, R63) reviewed for limited range of motion in the sample of 35. Findings include: 1. R39's Minimum Data Set (MDS) assessment dated [DATE] documents R39 is cognitively intact; requires extensive assistance of one person for bed mobility, transfers, dressing, toilet use, personal hygiene; does not walk, has functional limitation in range of motion to both lower extremities, and uses a wheelchair for locomotion. R39's Contracture Risk Evaluation dated 11/15/22 documents R39 is at high risk for developing contractures because R39 is confused at times, is non-ambulatory, needs assistance at times for positioning, has diagnoses which predisposes him to contractures. This same evaluation, signed by V9 (Restorative Nurse), does not include whether a range of motion program will be implemented or whether R39 previously received treatment…

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

Based on observation, interview and record review, the facility failed to ensure residents received nutritional supplement as ordered for two of two residents (R58, R35) reviewed for nutrition in a sample of 35. Findings include: A Dietitian Recommendation Process policy dated 1/2022 states, Dietitian recommendations will be completed in an organized and timely manner. In addition, this policy states, The Dietitian may make recommendations regarding resident care, which does not require a change in physician's orders. The recommendations will be documented. The Director of Nursing (DON) and the Food and Nutrition Services Manager are responsible for implementing these recommendations in their respective departments, and The Director of Nursing or designee will seek the physician's order changes in a timely manner. This policy states that these physician's order changes should be obtained in two to three days. 1. R58's weight log documents that on 11/4/22 R58's weight was 186.5 lbs (pounds). By 12/20/22, R58's weight had dropped to 179.2 lbs. This same weight log documents that by…

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

Based on observation, interview and record review, the facility failed to document appropriate indications for use of an antipsychotic medication and perform gradual dose reductions at least yearly for one of five residents (R39) reviewed for unnecessary medication in a sample of 35. Findings include: A Psychotropic Medication policy, dated as revised 11/28/2017, gives as its intent, Residents are free from unnecessary medication use. This policy states, Psychotropic medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but not limited to, antipsychotics. This policy states, These medications are to be given to treat a specific condition/medical symptom that is diagnoses and documented in the clinical record, and Additionally, Antipsychotic medication may be indicated for use if 1) Behavioral symptoms present a danger to the resident or others: 2) Expressions or indications of distress that are significant distress to the resident; 3) If not clinically indicated, multiple non-pharmacological approaches have been…

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 insulin was given as ordered for one of five residents (R25) reviewed for significant medication errors in a sample of 35. Findings include: A Medication Administration policy dated 1/11/2010 states, It is the policy of this facility to accurately administer medication following physician's orders. R25's physician's orders (POS) dated 6/2/2022 documents R25 receives Basaglar KwikPen insulin 28 units subcutaneously two times daily related to R25's diagnosis of Type 2 Diabetes Mellitus with Other Specified Complication. R25's Medication Administration Record (MAR) dated 1/31/23 documents R25 was supposed to receive Basaglar Kwikpen insulin at 8:00a.m. and 5:00p.m. that day, however, only the 5:00p.m. dose was administered. This same MAR also documented R25's blood sugar was 190mg/dl prior to breakfast on that date. On 1/31/23 at 10:48a.m., V10 (Licensed Practical Nurse/LPN) was standing at the medication cart in the hallway, preparing to pass residents' medications. V10 stated she was preparing to pass…

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.