Sullivan Healthcare & Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain the dignity of three (R10, R11, R12) residents by not providing Activities of Daily Living (ADL) timely out of six residents reviewed for ADL's in a sample list of 17 residents.Findings include:1.R10's Minimum Data Set (MDS) dated [DATE] documents R10 as severely cognitively impaired. This same MDS documents R10 is dependent of staff for oral hygiene, toileting, dressing, personal hygiene, transfers and requires maximum assistance from staff for bathing and bed mobility.R10's Care Plan intervention dated 1/12/23 documents staff will provide hygiene and grooming per R10's preferences. Ensure hair is in place before meals. Keep facial hair trimmed/shaved per R10's usual style. Fingernail care is on shower days and as needed. On 11/25/25 at 9:15 AM R10 was sitting in the resident lounge with another resident present. R10 had overgrown, unkempt mustache and facial hair long stubble. R10 had a piece of egg on his shirt leftover from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide timely and complete incontinence care for three residents (R9, R10, R13) out of six residents reviewed for Activities of Daily Living (ADL) in a sample list of 17 residents.Findings include:1. R9's Minimum Data Set (MDS) dated [DATE] documents R9 as moderately cognitively impaired. This same MDS documents R9 is dependent on staff for assistance with oral hygiene, toileting, bathing, dressing and personal hygiene.R9's Care Plan intervention dated 10/27/25 instructs staff to check (R9) for incontinence and to wash, rinse and dry perineum. On 11/24/25 at 9:48 AM V19 Certified Nurse Aide (CNA) stated R9 was assisted up out of bed at 6:50 AM, brought to the nurses station until breakfast, then assisted to and from the dining room and sat in the resident lounge. V19 CNA stated residents are 'normally' provided incontinence care when they arise, before lunch and then again at the change of shifts at 2:00 PM. V19 CNA stated R9 will 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 interview and record review the facility failed to report a resident's allegation of staff to resident abuse for one of five residents (R1) reviewed for Abuse in a sample list of 17 residents.Findings include:R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact.R1's Care Plan initiated 1/9/2025 documents staff are to allow resident time and opportunity to express feelings, anger or frustration. Provide empathy and validation of feelings. Allow resident time and opportunity to express self and verbalize frustrations. Approach in a calm, non-threatening manner.R1's Nurse Progress Note dated 10/13/25 at 9:53 AM documents R1 has been cursing and throwing objects at staff. (R1) was asked to wait a couple of minutes until staff finished with another resident that staff was caring for. This same note documents when staff entered R1's room to care for R1, he started making accusations that they (staff) are abusing him. This same note documents R1 was administered pain medication and R1…

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

Based on interview and record review the facility failed to provide the services of a Registered Nurse (RN) eight consecutive hours a day, seven days a week. This failure has the potential to affect all 70 residents in the facility. Findings include:On 8/14/25 at 4:40 pm, V1 Administrator/Registered Nurse (RN) provided RN staff timecards. V1 stated she had given survey team the wrong nursing schedule, initially. V1 confirmed the wrong schedule reflected V23, Registered Nurse worked Saturday August 2, 2025, and Sunday August 3, 2025, was an error. V1 stated (V23, RN) had not worked due to illness. V1 stated the updated working schedule she now provided is accurate. V1 stated V8, Registered Nurse/Assistant Director of Nursing worked Saturday 8/2/25 from 2:00 am to 6:00 am, leaving the facility short four hours of RN coverage that day. V1 provided her own timecard which included hours worked on 8/2/25. V1 thought she may have worked the floor to cover the four RN hours short. V1, Administrator/RN stated she has regional responsibilities in other facilities and had been training V3,…

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

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 70 residents in the facility. Findings include:On 8/12/2025 at 10:06AM, V16 (Cook) was actively supervising dietary operations in the facility kitchen. V16 reported the facility dietary service does not currently have a full-time designated manager. V16 reported not being a clinically qualified Certified Dietary Manager (also known as Certified Food Protection Professional) or having equivalent training. V16 denied meeting the State of Illinois standards to be a food service manager or dietary manager (required in states that have their own established standards to be a food service manager or dietary manager (483.60(a) (2)ii). V16 reported only completing a one-day course on food service sanitation which did not include any instruction on clinical nutrition. V16 denied:-being a dietician;-being a certified dietary manager;-having an associate's or higher degree in food service management or in…

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

Based on observation, interview, and record review, the facility failed to prevent the potential for physical cross-contamination of food and failed to maintain sanitary walk-in cooler floor surfaces. These failures have the potential to affect all 70 residents in the facility. Findings include: 1. On 8/12/2025 at 10:15AM, the kitchen walk-in cooler floor was soiled with food debris including a decomposed tomato, onion skins, and spilled beverages. On 8/14/2025 at 12:25PM, the cooler floor surfaces remained as above. 2. On 8/12/2025 at 10:25AM, the kitchen table-mounted can opener and receiver were soiled with dark and sticky food accumulations and metal shavings. On 8/14/2025 at 12:31PM, the above can opener remained soiled. V15 (Cook) was present and reported kitchen staff are supposed to clean the opener each time the opener is used. 3. On 8/12/2025 at 10:20AM, a bulk food storage container containing flour was located in the kitchen food pantry and contained a disposable foam cup being used as a food scoop. All portions of the foam cup were in direct contact with the flour. 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.

Based on interview and record review the facility failed to ensure the Director of Nursing, (required personnel) attended the quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 70 residents residing in the facility. Findings Include:The facility QAPI (Quality Assurance and Performance Improvement) Plan for (the facility name) dated 5/19/24 documents, At minimum the Regional Team and Facility Management team, along with the QAPI Steering Committee, will conduct a facility-wide system evaluation utilizing QAPI Self-Assessment. The facility provided accompanying document states the QAA meeting is conducted every three months and includes Key Personnel. A second document was provided with a list of Key Personnel. This list included V2, Director of Nursing.The facility QA Meeting typed sign-in sheet documents key personnel. At the top of the sheet is a handwritten date of July 15, 2025. The sheet documents V2, Director of Nursing's (DON) signature.On 08/14/25 at 2:45 pm V2, DON reviewed the Quality Assurance Meeting signature…

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 homelike environment for two (R7, R25) residents out of two residents reviewed for homelike environment in a sample list of 35 residents. 1). R25's Minimum Data Set (MDS) dated [DATE] documents R25 as cognitively intact. On 8/12/25 at 1:00 PM R25 was laying on her bed directly on the fitted sheet. R25's fitted sheet had several brown colored stains and was worn through so that the mattress could be seen. On 8/14/25 at 10:40 AM R25 was laying on her bed directly on her fitted sheet. R25's sheet was worn with three brown stains that were several inches in diameter. On 8/12/25 at 1:05 PM R25 stated the staff bring her clean sheets that are stained. R25 stated she would prefer to have sheets without 'someone else's stains' on them. On 8/14/25 at 11:30 AM V13 Certified Nurse Aide (CNA) stated most of the resident bed linens are stained and/or worn to the point you can almost see through them. V13 CNA stated she has had residents…

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 bathing and timely incontinence cares for a resident dependent on staff for hygiene. This failure affects one resident (R21) of two reviewed for Activities of Daily Living on the sample list of 35.Findings include: Resident Council meeting minutes (January 2025, February 2025, April 2025, May 2025, June 2025) document resident concerns with facility staff not answering resident call lights in a timely manner. The February 2025 minutes also document resident concerns with receiving showers in the facility.R21's Profile page (8/15/2025) documents R21 admitted to the facility on [DATE].R21's Medical Diagnosis page (8/13/2025) documents R21's diagnoses include Muscle Weakness, Parkinsonism (syndrome causing slowness of movement, muscle stiffness, tremor, and problems with balance and coordination), Left Femur Fracture, Severe Obesity, Chronic Obstructive Pulmonary Disease, Depression, and Anxiety Disorder.R21's Resident Assessment (7/6/2025)…

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 interview the facility failed to ensure the dignity of one (R7) resident out of three residents reviewed for dignity in a sample list of 35. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as severely cognitively impaired. This same MDS documents R7 is dependent on staff for transferring, toileting, bathing, dressing, bed mobility, eating and personal hygiene. 08/13/2025 8:00 AM R7 was reclined in her wheelchair in the resident lounge with other residents and staff present. R7 had a thick line of white mucous hanging from her Right lower cheek to the Right corner of her mouth. On 8/14/25 at 9:00 AM R7 was laying in her recliner in the resident lounge with other residents present. R7 had dried, thick white mucous on her lips and corners of her mouth. On 8/15/25 at 3:00 PM V2 Director of Nurses (DON) stated the staff should provide oral care for all residents who need assistance at least daily and as needed. V2 DON stated R7 requires total assistance from staff.

Based on observation, interview and record review the facility failed to initiate a grievance report in a timely manner, resulting in a delay in resolving the resident grievance. This failure affects one of two residents (R37) reviewed for grievances on the sample list of 35.Findings include:On 08/08/2025 at 10:40 AM V5, Ombudsman stated she had concerns about R37's missing jacket. V5 said V5 spoke with V1 Administrator on 6/17/25 but did not know if the jacket had been found or replaced. On 8/12/25 at 1:30 pm V1, Administrator stated she did not have any grievances about R37's missing jacket. On 8/12/25 at 3:00 pm V1 stated V1 found a grievance regarding R37's jacket, that V1 had forgotten about. V1, Administrator stated she called the V6, Facility Owner and got permission to order two jacket tops for R37. V1 then provided a grievance dated 8/6/25 (50 days after V5 notified V1) and the order summary sheet defining that two jackets were ordered dated 8/12/25 (today). V1 again stated she had no grievance in June regarding R37's jacket that she could recall. On 8/13/25 at 10:45 am V5,…

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 accurately encode a resident's health status on the Resident Assessment Instrument (Minimum Data Set) regarding falls. This failure affects one of two residents (R3) reviewed for falls/resident assessments on the sample of 30.Findings include:R3's Quarterly-Minimum Data Set (MDS) dated [DATE] documents R3 had a Brief Interview of Mental Status score of 10 out of a possible 15, indicating moderate cognitive impairment. R3's same MDS inaccurately documents R3 had no falls in the facility since the last quarterly MDS assessment.R3's A.I.M. (Assessment/Evaluation Intercommunicate Management/Intervention) for Wellness Event Record dated 3/5/25 at 5:25 pm, documents the following: Note Text: Event Details: (R3) appears to have experienced an alleged Intentional Change in Plane; Witnessed w/o (without) head involvement. Event was first noted on 03/05/2025 5:00 PM. Evaluation of the resident and event occurred on or about 03/05/2025 at 5:00 PM. Just prior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to identify, assess and provide treatment for pressure sores for one of one resident (R7) reviewed for pressure sores in a sample list of 35 residents. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as severely cognitively impaired. This same MDS documents R7 is dependent on staff for transferring, toileting, bathing, dressing, bed mobility, eating and personal hygiene. R7's Care plan intervention dated 3/28/23 instructs staff to float R7's heels in bed as needed, use pillows /cushions between to prevent skin to skin contact legs/ankles and feet, avoid pressure off feet against footboard, and avoid pressure of toes against mattress, rails, or footboard. R7's Physician Order Set (POS) dated August 2025 documents a physician order starting 11/01/2022 to complete a daily skin check. This same POS documents a physician order starting 8/14/25 to monitor the red area on the back of R7's Left Leg and Right Inner Leg. There are no previous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent cross contamination during incontinence care and failed to provide timely incontinence care for one (R2) out of three residents reviewed for timeliness of incontinence cares in a sample list of seven residents. Findings include: R2's undated Face Sheet documents medical diagnoses of Quadriplegia, Diabetes Mellitus Type II, Spinal Stenosis, Arthrodesis, Cervicalgia, Obesity, Radiculopathy Cervical Region, Sensorineural Hearing Loss, Neuropathy, Retention of Urine, Depression, Syndrome of Inappropriate secretion of Antidiuretic Hormone and Anxiety. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately cognitively impaired. This same MDS documents R2 depends on staff for all cares including toileting, bed mobility, transfers, showering and personal hygiene. R2's Care plan intervention dated 10/4/24 instructs staff to place an incontinence brief on R2 when up and to check incontinence brief every two hours and change as…

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 post fall interventions for (R2 and R3), and failed repeatedly to recognize, document and investigation falls from bed (R3). These failures affected two of four residents (R2, R3) reviewed for falls on the same list of 25. Findings include: 1. R2's Diagnoses Sheet dated 8/22/23 documents the following: Dementia in Other Disease Classified Elsewhere, Unspecified, Other Seizures, Weakness and Other Osteoporosis Without Current Pathological Fracture. R2's Minimum Data Set, dated [DATE] documents R2's Brief Interview of Mental Status score of seven out of a possible 15, indicating R2 has severe cognitive impairment. R2's Medication Administration Record dated December 2024, document the following: Monitor all bruising to upper extremities. Notify the Physician if any worsening or changes in condition. On 12/12/24 at 10:50 am R2 was lying in bed. R2's bed was elevated approximately 42 inches (included the mattress) off the floor. R2'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 protect the residents' right to be free from verbal and physical abuse by another resident. These failures affect four (R1, R2, R3, R4) residents out of four residents reviewed for abuse in a sample list of seven residents. Findings include: The facility policy titled Abuse Prevention effective May 2021 documents the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal abuse is the use of oral, written, or gestured language…

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

Based on interview and record review, the facility failed to ensure the residents were informed of and understood their rights, while living in the nursing home. This failure has the potential to affect all 71 residents residing in the facility. Findings include: On 9/11/24 at 11:00 AM, during the resident group meeting, (R10, R12, R38, R40 and R48) stated, No, we don't get our resident rights told to us during Resident Council meetings. We received a booklet when we were first admitted but that was a while ago. Resident Council meeting minutes dated for the month of April, May, June, July, August and September 2024 did not document Resident rights were discussed during the Resident Council meeting. V8, Activity director stated on 9/12/24 at 11:29 AM No I do not go over the Residents Rights in our meetings, The facility's Illinois Long-Term Care Ombudsman Program, Residents' Rights for People in Long Term Care Facilities, revision date 11/2018 documents As an individual living in a long-term care facility, you retain the same rights as every citizen of Illinois and of the United…

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 deliver mail to residents on Saturdays. This failure has the potential to affect all 71 residents residing in the facility. Findings include: On 9/11/24 at 11:00 AM, during the resident group meeting (R10, R12, R38, R40 and R48) were present and stated, We do not get mail on Saturdays. On 9/12/24 at 1:30 PM V1 Administrator stated, The residents do not get the mail on Saturdays due to the post office does not deliver the mail to us on Saturdays. On 9/12/24 at 2:47 PM, V20, Local Post Office Mail Clerk stated, Yes, we deliver mail to the nursing home on Saturdays. We put the mail in their mail box. The facility's Illinois Long-Term Care Ombudsman Program, Residents' Rights for People in Long Term Care Facilities, revision date 11/2018 documents, Your facility must deliver your mail promptly. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 9/10/24 documents 71 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to employ a qualified Director of Food and Nutrition Services. This failure has the potential to affect nearly all 71 residents residing in the facility, who consume food prepared in the facility kitchen (with the exception of four residents who receive nothing by mouth). Findings include: On 9/10/24 at 9:22 AM, V1, Administrator, confirmed there was no Dietary Manager for the facility. On 9/10/24 at 9:50 AM, V3, Cook, was seen actively managing and directing dietary personnel and food preparation activities in the facility kitchen. V3 stated, I do not have a CDM (certified dietary manager) certificate, all I have is an FSS (food service sanitation) certificate. V3 confirmed the FSS was an 8 hour cooking sanitation training, not managerial in nature. V3 reported not meeting the state requirements for a Director of Food Service (Dietetic Service Supervisor) by further stating, I have no formal training or education, just a GED (graduate equivalency diploma) is about all I have, I have no military experience, I…

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 implement food storage and leftover tracking processes, failed to maintain bulk food cleanliness, and failed to maintain kitchen equipment cleanliness to prevent the potential for food contamination. These failures affect nearly all 71 residents residing in the facility who consume food prepared in the facility kitchen (all with the exception of four residents who receive nothing by mouth). Findings include: On 9/10/24 at 10:00 AM, there were no dates on the food items stored in the facility dry storage area to indicate when the items were received. V3, Cook, stated, We are supposed to be using a 'first in first out' rotation, we really should be dating everything when received but it really just depends on who puts things away. On 9/10/24 at 10:05 AM, there was a rolled plastic bag of partially used mixed salad in the facility's walk-in refrigerator which was not dated or labeled to indicate when the bag was opened, nor when the contents should be used by. V3 stated, We are supposed to be dating all…

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 provided Activities of Daily Living assistance (ADL's) for six out of seven residents (R12, R17, R32, R38, R40 and R48) reviewed for ADL's assistance on the sample list of 28. Finding include: 1. R17's Current Diagnoses Sheet documents the following: Quadriplegia Unspecified, Intracranial Injury with Loss Of Consciousness Of Unspecified Duration, Sequela, Tracheostomy (surgically inserted airway access tube in the neck) Status, and Gastrostomy (surgically inserted feeding tube in the abdomen) Status. R17's Care Plan History form dated 8/2/23 documents the following: PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on 1-2 staff for personal hygiene and oral care. On 09/10/24 at 10:18 am during the initial tour of the facility, R17 was lying in bed. R17 had a Tracheostomy tube noted on the anterior aspect of her neck. R17 also had Gastrostomy feeding tube and Tracheostomy suction machine set-up on her bedside table. R17 had bilateral hand mitten restraints. R17 was non-verbal. R17 had crusted white…

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

Based on observations, interviews and record review the facility failed to implement enhanced barrier precautions that required personal protective equipment to be used during care for residents with Tracheostomy airway access, Gastrostomy feeding tubes, pressure ulcers, urinary catheters and intravenous access port. This failure affected five of five residents (R12, R14, R15, R39 and R62) reviewed for enhanced barrier precautions on the sample list of 28. Findings include: 1.) On 09/10/24 at 9:30 am R14 seated in a bedside recliner. R14 has an indwelling urinary catheter bag attached to the foot rest of the recliner. The urine in R14's urinary catheter tubing is cloudy with an excessive amount of sediment present. R14 does not have an Enhanced Barrier Precaution (EBP) signage posted in or out side R14's room to alert staff entering R14's room to provide care. There is no Personal Protective Equipment (PPE) set up of equipment present inside or outside R14's room, that staff are required to wear during care. On 9/10/24 at 1:45 pm V4, V5, and V16, Certified Nursing Assistants (CNA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify a family representative of a decrease in dosage of antipsychotic medication. This failure affected one of one resident (R35) reviewed for family notification on the sample list of 28. Findings include: R35's Minimum Data Set, dated [DATE] documents R35 has moderate cognitive impairment. R35's Medication Administration Record (MAR) dated September 2024 documents the following: Risperdal (antipsychotic, Risperidone) Oral Tablet, Give 0.25 mg by mouth. three times a day related to Bipolar Disorder, Unspecified Schizoaffective Disorder, (and) Schizophrenia Unspecified. -Start Date 03/26/2024. -D/C (discontinue) Date 09/04/2024. R35's same September MAR documents R35's Risperdal Oral Tablet, give 0.25 mg by mouth, two times a day (decreased frequency, documented three times a day above). Start Date 09/05/2024 at 0800 am. D/C Date 09/09/2024 (Monday) at 1:02 pm. R35's same September MAR documents R35 did not receive the noon dose from 9/5/24, 9/6/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to resolve a resident representative grievance to provide a specialized wheelchair in a timely manner. This failure affects one of one residents (R35) reviewed for grievances on the sample list of 28. Findings include: R35's Minimum Data Set, dated [DATE] documents R35 has moderate cognitive impairment and requires a wheelchair for mobility. R35's Grievance/Complaint Report signed by V1, Administrator, submitted to the facility by V15, Family Representative/Guardian, dated initially 2/14/24 and also dated as unresolved on 5/15/24 documents the following: Family requested a new wheelchair. Explained to (V15) that public aid (insurance) would pay for a new one every three years and to use (R35's) money for her (R35's) funeral expenses, so (V15) didn't have to pay for it (wheelchair). The same Grievance/Complaint Report signed by V1, Administrator, documents: Change out wheelchair to whatever (R35) wants that day. Explained to (V15) as soon as…

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 remove secured hand mitten restraints according to the plan of care, for one of one residents (R17) reviewed for restraint on the sample list of 28. Findings include: R17's Current Diagnoses Sheet documents the following: Quadriplegia (incomplete, resident can still move her arms as evidenced below) Unspecified, Intracranial Injury With Loss Of Consciousness Of Unspecified Duration, Sequela, Tracheostomy Status, and Gastrostomy Status. R17's Current Physician Order Sheet documents the following: Nursing Intervention: May use Appliances: Wheelchair; Bilateral Full Side rails; Mittens: Trach; Padded Side Rails, No Directions Specified Active as of 10/18/2022. R17's Care Plan dated as revised 8/24/24 documents the following: The resident uses mittens to bilateral hands for safety and prevention of extubating G-Tube/Trach r/t TBI and neurological devastation. Resident frequently pulls (therefore, incomplete quadriplegia) Trach and G-tube. She is unable to fully comprehend the consequences of her actions.…

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 and implement an individualize care plan to include an indwelling urinary catheter for a resident. This failure affects one (R39) of 20 residents reviewed for care plans in a sample of 28. Findings include: The Physician's Orders Sheet (POS) dated September 24 documents R39 has the following diagnosis: Retention of Urine and Unspecified Urinary Tract Infection. The same POS has the order for R39 to have a urinary catheter 16 French with 10 milliliter bulb. Change every 28 days and whenever necessary. The order was dated 8/9/24. R39's care plan dated 9/12/24 did not have a category plan and interventions documented for R39's urinary indwelling catheter. On 9/12/24 at 2:15 PM. V7, Minimum Data Set/Care plan Coordinator stated V1, Administrator told V7 on September 12, 2024 about R39's care plan not covering R39's catheter. V7 corrected the care plan by adding information to the Care plan for R39's catheter care. The facility's policy titled Comprehensive Care Planning with the revision date of 11/1/17 documents under…

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

Based on observation, interview and record review the facility failed to assess new, facility acquired Stage II pressure ulcers upon notification, resulting in a delay in initiating a pressure ulcer treatment in a timely manner. This failure affected one of two residents (R14), reviewed for pressure ulcers on the sample list of 28. Findings include: R14's Physician Order Summary (POS) report dated 9/13/24 documents the following diagnoses: Diabetes Mellitus II with Diabetic Polyneuropathy, Spinal Stenosis, Cervicalgia, Obesity, and Unspecified Quadriplegia. There was no pressure ulcer treatment documented in R14's medical record or on R14's POS until after the observations and interviews below. On 9/10/24 at 1:45 pm V4, V5, and V16, Certified Nursing Assistants (CNA) transferred R14 via full mechanical lift from R14's wheelchair to bed. V16 CNA and V5 CNA donned gloves after hand washing, pulled resident pants down to calf while V4 prepared washcloths with no rinse cleaner for urinary indwelling catheter and peri-care. V5 CNA completed catheter care. V5 and V16 repositioned R14 to 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 observation and record review, the facility failed to maintain NPO (nothing by mouth) status by administering a medication to a resident with a tracheostomy. This failure affected one resident (R15) during medication pass observation. Findings include: R15's Physician Order Sheet (POS) dated 9/13/24, documents medication administration per G-tube (gastrostomy), crush medications, cocktail and administer s bolus per MD (medical doctor). This same POS documents Gastrostomy tube (G-tube) (placement) 11/1/22, and Tracheostomy (placement) 11/1/22. R15's Dietary Admission/Quarterly Evaluation dated 8/20/24, documents R15 is NPO, tube feeding, diagnosis of Dysphagia, brain injury, and dependent. R15's Care Plan dated 9/13/24, documents R15 is not to have anything by mouth. There is no documentation in R15's Care Plan of R15 having a Tracheostomy. On 9/11/24 at 11:33 AM, V2 Director of Nursing (DON), was observed during a medication pass was giving R15 medications. R15's POS documents an order for Hyoscyamine 0.125 milligrams sublingual, give one tablet twice a day. V2 placed one…

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 rehabilitation services to four (R1, R2, R3, R4) residents out of four residents reviewed for Rehabilitation Services in a sample list of four residents. Findings include: The Facility Daily Census dated 3/19/24 documents 66 residents reside in facility. The Facility Assessment updated 3/1/2024 documents the facility will provide therapy services including Physical Therapy (PT), Speech Therapy (ST) and Occupational Therapy (OT). The facility document titled, 'Termination of Therapy Services Agreement' dated 2/13/24 documents, (The Therapy Company) is providing a five day written notice of termination of Therapy Services with facility due to failure to maintain payment terms, pursuant to Section 5.2.5 of the Therapy Services Agreement. (Therapy Company's) final date of service will be Sunday, February 18, 2024. 1.) R1's undated Face Sheet documents R1 was admitted to facility on 1/10/2024. R1's Minimum Data Set (MDS) dated [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 interview and record review, the facility failed to provide the services of a Registered Nurse for eight consecutive hours seven days per week. This failure has the potential to affect all 65 residents residing in the facility. Findings include: The facility's Nurse Schedule dated for July 2023 documents on 7/6/23, 7/7/23, 7/10/23, 7/11/23, 7/12/23, 7/15/23, 7/16/23, 7/21/23, 7/24/23, 7/25/23, 7/29/23, and 7/30/23 there was not a Registered Nurse on duty for 8 consecutive hours at the facility. On 8/2/23 at 12:35 PM, V1 (Administrator) acknowledged the nurse schedule as provided and stated, I didn't know the RN (Registered Nurse) hours had to be consecutive. At 1:25 PM, V1 provided the clock time sheet for V9 (Registered Nurse/RN) and stated, V9 is not listed on our schedule, she just started 7/11/23 and she worked some dates in July, I'm not saying there still isn't going to be some shifts not covered. The facility's Resident Census and Conditions of Residents dated 8/1/23 documents 65 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a Level 2 Pre-admission Screen to determine any needed psychiatric services. This failure affects one resident (R13) out of two reviewed for Pre-admission Screening on the sample list of 27. Findings include: On [DATE] at 10:44 AM, R13 was experiencing an intermittent cough while speaking and rubbed her hands vigorously on the sides of her head in frustration and uttered a profane explicative. R13 experienced remarkable difficulty in organizing words and formulating words into sentences. R13's Medical Diagnoses include Schizophrenia, Major Recurrent Depressive Disorder, Pseudobulbar Affect, and Altered Mental Status. R13's Minimum Data Set, dated [DATE] documents R13 experiences fluctuating inattention, disorganized thinking, has little interest or pleasure in doing things, and feeling tired with little energy. This same Minimum Data Set documents R13 exhibits behavioral symptoms not directed at others such as hitting or scratching…

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 assist dependent residents with showering. This failure affected two of two residents (R23, R62) reviewed for Activities of Daily Living on the sample list of 27. Findings include: The Bathing/Shower Policy dated 3/20/23 documents baths and showers are given to ensure adequate hygiene needs are met. A bath/shower is scheduled for all residents in the facility at least weekly. 1. On 8/01/23 at 1:32 PM, R23 stated she does not get showers twice per week like she should be and R23 stated getting a shower is very important to her as she used to take showers daily. R23 stated she would at least like to get a shower twice per week. R23 stated staff will inform her on her planned shower day that she is due for a shower and then never actually give her a shower. R23's Minimum Data Set, dated [DATE] documents R23 is cognitively intact and is totally dependent on at least two staff for showering. The Bathing Schedule dated 8/2/23 documents R23 is scheduled 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to change residents' oxygen tubing, nebulizer tubing, humidifier bottles and failed to provide sanitary storage for those items. The facility also failed to clean machines and provide sanitary storage for Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPap) machines. These failures affect three of four residents (R19, R62, R37) reviewed for respiratory care on the sample list of 27. Findings Include: The Oxygen Therapy Policy dated March 2019 documents staff are to change oxygen tubing/mask/cannula on a weekly basis. Date tubing changes and document on the treatment sheet. If using unfilled humidifier bottles; empty, rinse and refill daily with distilled water, and wash with soap and water as needed. Humidifier changes and cleaning is to be documented on the treatment sheet at the time of occurrence. The CPAP/BiPap Policy dated 3/8/13 documents machine circuits are to be cleaned every week and as needed…

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

Based on interview and record review, the facility failed to maintain accurate resident medical records. This failure affected one of 27 residents (R25) reviewed for medical records on the sample list of 27. Findings include: R25's admission Record documents V1 (Administrator/Registered Nurse) as R25's Guardian and first person to be notified in the event of an emergency. V2, Director of Nursing is documented as the second emergency contact. A third emergency contact documents V17 (R25's Pastor). On 8/2/23 at 4:45 pm, V15 (Social Service Director/SSD) stated V1 (Administrator) is not R25's Guardian. V15 (SSD) stated R25's chart is wrong. V1 was designated health care surrogate when there were no relatives or friends available to assume the responsibility. V15 (SSD) stated Guardianship is a legal process that the facility has not initiated. On 8/3/23 at 10:15 am, V1 (Administrator/RN) and V2 (Director of Nursing/DON) confirmed V1 and V2 are listed as emergency contacts for R25. V1 stated she is not R25's Guardian that it was an error in documentation.

Based on observation, interview, and record review, the facility failed to remove contaminated gown and gloves before leaving a contact isolation room, during pressure ulcer treatment. This failure affected one of two residents (R2) reviewed for pressure ulcer/transmission-based precautions on the sample list of 27. Findings include: R2's Lab and Provider Reports wound culture dated 12/16/19, and 2/13/20, left leg was submitted by V1 (Administrator/Registered Nurse) on 8/2/23 at 11:07 am. V1 stated V1 spoke with IDPH (unidentified staff) in infection control for LTC, and was told R2 should remain on contact isolation precaution indefinitely, due to R2's positive wound culture due to the bacteria being highly contagious. R2's Lab and Provider Reports documents the resistant bacteria, Carbapenem Resistant Acinetobacter Baumannii was present in R2's left leg wound. R2's Care Plan updated 8/2/23 documents: Resident is on contact isolation related to Infection process. Resident will follow contact isolation guidance thru next 92 days. The same care plan documents the following: Upon gown…

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.