Evercare Of Swansea

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to provide reasonable access to a telephone in an area where calls can be made without being overheard for 1 of 3 residents (R2) reviewed for communication with privacy in the sample of 23.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including depression, hypertension, and heart failure.R2's Minimum Data Set, dated [DATE] documented R2 was moderately cognitively impaired.R2's 7/25/25 Progress Note documents R2 became upset because he wanted to use the phone, but the nurse was already using it.On 8/20/2025 at 9:10 AM R2 stated V14, Licensed Practical Nurse (LPN), would not allow him to use the phone at the nurse's station. He stated, I have the right to use the phone.On 8/22/25 at 10:27 AM, V14 stated R2 wanted to use the phone, but she asked him to finish up his call because there were three other residents waiting in line for the phone, and V14 needed to make important nursing callsOn 8/22/25 at 10:15 AM, V2,…

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

Based on interview and record review the facility failed to implement its written policy by not ensuring that required background checks were completed prior to allowing direct care staff to work with residents. This failure had the potential to place all 52 residents living in the facility. Findings include:V37's, Certified Nursing Assistant, CNA, personnel file documented R37 was employed by facility beginning on 3/3/2025 through 5/15/2025. There was no Criminal Background Check completed by the facility; however, the facility did have a background check from previous employer dated 11/27/2024. V1, Administrator, stated Ideally this facility should've done a background check. V1 stated (V37) came from a sister facility and just kind of showed up one day. V2, Director of Nursing, DON, stated Typically when a staff member requests a transfer from a sister facility, we would call that facility and let them know the staff is requesting a transfer. There are new procedures put in place now that onboarding and background checks are to be done. Facility's undated abuse policy states 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 interview and record review, the Facility failed to ensure residents were free from misappropriation of property for 1 of 6 residents (R10) reviewed for abuse in the sample of 17.1.R10's Face Sheet documents R10 was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol-induced dementia and need for assistance with personal care.R10's Minimum Data Set (MDS) dated [DATE] documented R10 was moderately cognitively impaired with inattention and disorganized thinking and ambulated with walker.R10's Care Plan does not address risk of abuse and neglect.The Facility's Initial Report sent to the Illinois Department of Public Health (IDPH) on 2/18/25 documents R10 notified V17, Social Services Director, of allegation of misappropriation of money, and an investigation was initiated.The Facility's Abuse Investigation Report by V46, Former Administrator, documents, On 2/18/25 (V17) made a phone call when (R10) was in her office to (V36, R10's Family) regarding (R10)'s debit card…

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

Based on interview and record review, the facility failed to report allegations of exploitation immediately to the Executive Director for 1 of 3 residents (R5) reviewed for reporting of abuse in the sample of 17.Findings include:R5's incident note dated 7/17/2025 at 2:30PM documents R5 was a resident at this facility with a BIMS of 15 and diagnosed with the following but not limited to: Major Depressive Disorder, recurrent moderate Chronic Obstructive Pulmonary Disease, Unspecified Type 2 Diabetes with Hyperglycemia, and essential primary hypertension, Chronic Congestive Heart Failure. At approximately 2:30PM on 7/17/2025, an Illinois Department of Public Health surveyor reported to V1, Administrator, that there was an allegation of an inappropriate relationship between R5 and former staff members V37, V35, Certified Nurse's Aides, CNAs, and an unknown staff member. On 7/22/2025 at 11:35AM V32, CNA, stated There were 2 staff that would make R5 food, and he would pay their bills, give them gifts, give them the keys to his house, put money in their cash app. The staff were V35 and…

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

Based on interview and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) meetings consisted of the required members. This failure has the potential to affect all 57 residents residing in the facility. V1 (Administrator) provided an attendance record from the last QAPI meeting, which was dated 4/25/25. The provided sign in sheet does not document the line labeled as Medical Director was in attendance, as it is blank. V1 stated the last QAPI meeting at the facility was on 4/25/25 and confirms V31 (Medical Director) was not in attendance. V1 stated the meeting was last minute and V31 wasn't able to attend. Review of the facility policy titled QAPI Program with a reviewed date of 6/1/25 documented QAPI principles will drive the decision making within our organization .QAPI activities will be integrated across all the care and service areas of our organization. Each area should have a representative on the QAA (Quality Assessment and Assurance) committee. The facility census report dated 7/8/25 documented 57 residents currently reside in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a safe, clean, well maintained, homelike environment for 8 of 8 residents (R1, R6, R7, R11, R16, R19, R20, & R21) reviewed for physical environment in the sample of 23. This failure has the potential to affect all 57 residents in the facility. Findings Include: On 6/24/25 at 8:26 AM room [ROOM NUMBER] was observed with a brown sticky substance on the floor throughout the room and restroom. Dirt and debris were observed under the bed and nightstand. A large amount of dried feces and urine were observed on the toilet seat. On 6/24/25 at 8:30 AM a sign noting DO NOT USE was observed on the toilet lid of room [ROOM NUMBER] restroom. The floor along the cove base was observed with a brown/black buildup throughout the room and restroom. Debris and dirt were observed under the bed and nightstand. On 6/24/25 at 8:50 AM a dark dirty buildup was observed all around the cove base on the floor of the 200 unit. The cream-colored cove base was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement an infection control training program for staff. This failure has the potential to affect all 57 residents residing in the facility. Findings Include: On 7/8/25 at 10:30 AM, V1 (Administrator) stated that she does not know the last time staff were trained on infection control program and confirms she does not have any reproducible evidence to support training occurred. V1 stated that staff will be in-serviced on infection control at their upcoming staff meeting. V32 (Licensed Practice Nurse) is documented as being the facility's certified Infection Preventionist. On 7/9/25 at 10:25 AM, although requested, V11 (Vice President of Clinical Services) confirmed a policy regarding infection control training was not available. The facility assessment dated [DATE] documented the facility has 90 licensed beds for long term care nursing services, which includes the care of infectious organisms. The facility census report dated 7/8/25 documented 57…

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 implement a nurse aide training program which continues competence equivalent to no less than 12 hours per year. This failure has the potential to affect all 57 residents residing in the facility. Findings Include: On 7/8/25 at 10:30 AM, V1 (Administrator) stated that she does not know the last time staff received nurse aide training and confirms she does not have any reproducible evidence to support training occurred. V1 stated that staff will be inserviced on nurse aide training competencies at their upcoming staff meeting. The facility assessment dated [DATE] documented the facility has 90 licensed beds for long term care nursing services. On 7/9/25 at 10:25 AM, although requested, V11 (Vice President of Clinical Services) confirmed a policy regarding nurse aide training was not available. The facility census report dated 7/8/25 documented 57 residents currently reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement a behavior training program for staff. This failure has the potential to affect all 57 residents residing in the facility. Findings Include: On 7/8/25 at 10:30 AM, V1 (Administrator) stated that she does not know the last time staff received behavior training and confirms she does not have any reproducible evidence to support training occurred. V1 stated that staff will receive behavior training at their upcoming staff meeting. V1 also confirms the facility currently serves residents with mental health conditions. The facility assessment dated [DATE] documents the facility accepts residents with the following psychiatric/mood disorders: Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. This same assessment documented the facility has an average number of 40-60…

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 abuse to the administrator immediately after an allegation is made and the state agency within the 2-hour timeframe for 2 of 3 residents (R2, R3) reviewed for abuse reporting in the sample of 5. Findings include: 1. R2's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including diabetes, hemiplegia/hemiparesis, anemia and anxiety. R2's Undated Care Plan no documentation resident was at risk for abuse. R2's Minimum Data Set (MDS) dated [DATE] documents she was alert, uses wheelchair, requires partial assist with sit to stand and submax assist with transfer. On 6/10/2025 at 1:07 PM V4, Certified Nurse's Aide, CNA, stated V4 was familiar with R2 and assisted V3, CNA, to care for her on 5/11/2025. V4 stated V3 got R2 in the stand-up lift and then she left the room to get towels. V4 stated when she reentered R2's room she was very upset and stated that V3 hurt her, abused her and hurt her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly investigate allegations of abuse for 2 of 3 residents (R2, R3) reviewed for abuse investigations in the sample of 5. Findings include: 1.R2's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including diabetes, hemiplegia/hemiparesis, anemia and anxiety. R2's Undated Care Plan no documentation resident was at risk for abuse. R2's Minimum Data Set (MDS) dated [DATE] documents she was alert, uses wheelchair, requires partial assist with sit to stand and submax assist with transfer. On 6/3/25 at 1:10 PM, when asked if staff treat her nicely, she shook hand to indicate so so. Surveyor asked what she meant by that, and she responded, one of the CNAs (Certified Nurse's Aides) yanked me out of the 'it and spin' and I landed on the floor. R2 stated this happened on Mother's Day (5/11/2025.) She said it was not an accident. R2 stated She told me, 'Come on, if you don't, I'll get you to move' and grabbed…

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 specialized rehabilitative services following a physician order for 1 of 2 (R4) residents investigated for being bed bound. Findings include: R4's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R4's EMR dated 2/2/24 documents a diagnosis of Chronic Obstructive Pulmonary Disease, unspecified; Chronic Diastolic Congestive Heart Failure, Morbid (Severe) Obesity, and other symptoms and signs involving the musculoskeletal system. R4's Care Plan dated 4/10/25 documents Impaired Physical Mobility. R4's MDS (Minimum Data Set) dated 4/3/25 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident requires substantial/maximal assistance for roll left and right. The MDS documents that all other mobility assessments were not attempted due to medical conditions or safety concerns. R4's Physician Order dated 3/26/25 documents BMP (Basic Metabolic…

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

Based on observation and interview, the facility failed to maintain clean, sanitary shower rooms for 4 of 4 residents (R1, R2, R3 and R5) reviewed for environment in a sample of 5. Findings include: On 4/8/2025 at 11:05 am, R1 stated he has seen mold in the 100-hall shower room. These showers have a sign with the words bath room on them. R1 stated this is the only place he has also noticed the smell of mold. On 4/8/2025 at 11:10 am a black, slimy appearing substance was noted in the corner junctions of the shower in the 200-hall shower room. On 4/8/25 at 11:10 am, R2 noticed a little bit in the facility and her bathroom. The bathroom has a sign marked out of order. A scattered blackish substance noted on the floor in R2's bathroom. On 4/8/2025 at 11:15 AM, V5, Certified nursing assistant, (CNA) stated that she has noticed mold in the bathroom and the shower room on the 100-hall. On 4/8/25 at 11:15 AM, V6, CNA, stated she has noticed mold in the shower room on the 100-hall and the shower room also smells like mold. On 4/8/2025 at 11:20 am, V7, Medical records/transport stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide information, obtain consents, and offer influenza (flu) vaccination for 4 of 4 residents (R1, R2, R3, R5) reviewed for Influenza immunization in the sample of 12. Findings include: 1. R1's Face Sheet documents an admission date of 2/7/2024 with diagnoses to include Dementia, Legal Blindness, Hypertension, Bipolar. R1's Minimum Data Set, MDS, dated [DATE] documents R1 is moderately cognitively impaired. R1 is independent with transfers and requires supervision with ambulation. R1's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. R1's paper chart documents vaccine on the following date: Influenza 10/19/2020. There was no documentation in R1's medical record that the facility provided R1 with information on influenza vaccination and obtained consent for vaccination. 2. R2's Face Sheet documents an admission date of 10/4/2021 with diagnosees to include Chronic Obstructive…

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 information, obtain consents, and offer COVID-19 vaccinations to 4 of 4 residents (R1, R2, R3, R5) reviewed for COVID-19 immunization in the sample of 12. Findings include: 1. R1's Face sheet documents an admission date of 2/7/2024 with diagnoses to include Dementia, Legal Blindness, Hypertension, Bipolar. R1's Minimum Data Set, MDS, dated [DATE] documents R1 is moderately cognitively impaired. R1 is independent with transfers and requires supervision with ambulation. R1's Preventive health care tab in Electronic Medical Record, EMR, showed no documentation or entries regarding any vaccines. R1's paper chart documents vaccine on the following date: COVID 19 11/6/2023. There was no documentation in R1's medical record that the facility attempted to provide R1 with information on the COVID-19 vaccination or obtain consent for this vaccination. 2. R2's Face sheet documents an admission date of 10/4/2021 with diagnoses to include Chronic…

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 prevent significant medications errors by ensure medications are available for 2 of 5 residents (R2, R5) reviewed for significant medication error in the sample of 12. Findings Include: 1. R2's Face Sheet documents an admission date of 10/402021 and diagnoses include Hypertension, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes. R2's order sheet dated 10/25/2024 documents Metoprolol Tartrate Tablet 25 milligrams (mg), Give 1 tablet by mouth two times a day related to Essential Primary Hypertension. R2's Medication Administration Record (MAR) dated 3/1/2025-3/31/2025 documents Metoprolol Tartrate 25mg not administered on 3/1, 3/2 AM and PM, 3/3 AM, 3/7 AM and PM with no reason documented as to why not given. R2's Minimum Data Set, MDS, dated [DATE] documents R2 has no cognitive deficits and is independent with transfers. Uses wheelchair for mobility. R2's Care Plan updated 3/13/2025 R2 has Congestive Heart Failure and Hypertension. Intervention:…

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, Observation, and Record Review, the facility failed to provide a Registered Nurse (RN) for a minimal of eight hours per day seven days per week and failed to have a Director of Nursing (DON) on a full-time basis. These failures have the potential to affect all 39 residents residing in the facility. The Findings Include: V1, Administrator, stated they have been without a Director Of Nursing (DON) since 11/27/24. V1 stated they interviewed V2, DON, and offered her the position on 12/13/24, however, V2 did not accept the position until 12/20/24. V1 stated that V2, DON, did not start until 1/6/25. On 1/15/25 at 8:05 AM, upon entrance to the facility, there were only three Certified Nursing Assistants (CNAs) and one Licensed Practical Nurse (LPN) on duty. V1 arrived around 8:15 AM and began passing medications on the 100-Hall. V1 stated she had an agency nurse call off and the DON called off. On 1/15/25 at 11:02 AM, V1 stated the Nurses work 12-hour day shift from 6:00 AM to 6:00 PM and 12-hour night shift from 6:00 PM to 6:00 AM. V1 stated she staffs with two nurses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, Observation, and Record Review, the facility failed to provide sufficient staffing to care for resident needs, including assisting a resident to get out of bed, and answering call lights, for 3 of 4 residents (R2, R3, R4) reviewed for sufficient staffing in the sample of 4. The Findings Include: 1. R3's Face Sheet, dated 1/14/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Congestive Heart Failure (CHF), Major Depressive disorder, Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus (DM) with Polyneuropathy, Hypertension (HTN), and Intestinal obstruction. R3's Care Plan, dated 12/18/24, documents R3 uses anti-anxiety medications related to (r/t) anxiety disorder. R3 uses multiple antidepressant medication r/t major depressive disorder. R3 may display symptoms of crying or sadness r/t depression. R3 Resident utilizes a wheelchair for mobility. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact and is dependent on staff for…

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) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 40 residents who reside in the facility. Findings include: On 12/12/24 at 3:30 PM V2, Regional Nurse, stated the facility's Director of Nursing (DON) walked out on 11/15/24 without notice and no new DON has been hired V2 stated she is not here everyday and admitted there is not Registered Nurse (RN) coverage everyday because V4, RN is the only other RN working in the facility and she only works 3 days a week. V2 stated they are trying to hire more RNs but do not use agency RNs just for RN coverage and only use agency if there is need for an RN to do intravenous (IV) medications. The facility's schedule dated November 2024 documents there was no RN coverage on November 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 25th, 26th,28th or 30th. The facility's schedule dated December 2024 documents there was no RN coverage on December 1st, 3rd, 6th, 9th, 12th, 14th or 15th. On 12/17/24 at…

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

Based on interview and record review the facility failed to administer ordered medications to 4 of 4 residents in the sample of 12. Findings include: On 12/17/2024 at 10:00AM R8 stated We did not get our meds on Sunday morning (12/15/2024). The nurse down here did not show up and the nurse on the other end refused to give us our meds. I have heart issues and some people have mental illness and should not go without meds. R8's Facesheet documents an admission date of 10/11/2021. Diagnosis include Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Essential Hypertension. On 12/17/2024 R8's medication administration records dated 12/1/2024-12/31/2024 show the following medications not signed out as administered on 12/15/2024 at 8:00AM: Brillinta 90mg, Acidophilus, Aspirin 81mg, Escitalopram 10mg Escitalopram 5mg, Glipizide 5mg, Lisinopril 2.5mg, Loratadine 10mg, Potassium 10meq, Vitamin D 3 5000 units, Ferrous Sulfate 325mg, Metoprolol 25mg, Cyclobenzaprine 5mg, Gabapentin 100mg, Symbicort inhaler, insulin LisiPro 5 units. R9's Facesheet documents an admission date of…

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

Based on Observation, Interview, and Record Review, the facility failed to administer ordered medications, resulting in 4 of 4 residents missing medications in the sample of 12. Findings include: On 12/17/2024 at 10:00AM R8 stated We did not get our meds on Sunday morning (12/15/2024). The nurse down here did not show up and the nurse on the other end refused to give us our meds. I have heart issues and some people have mental illness and should not go without meds. On 12/17/2024 at 10:15AM R9 stated On Sunday (12/15/2024) no one gave us our meds. The nurse down on the other end refused and we didn't get any. R8's Facesheet documents an admission date of 10/11/2021. Diagnosis include Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Essential Hypertension. R8's order sheet dated 10/2/2024 documents Insulin Lispro 100 units/ml inject 5 units subcutaneous, subq, 3 times daily at 8:00AM, 12:00PM, 4:00PM. R8's medication administration sheet dated 12/15/2024 does not have documentation that Insulin Lispro 5 units was administered at 8:00AM R8's order sheet dated 1/30/2024…

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, observation, and record review, the Facility failed to ensure food was stored, prepared, and served in a manner that prevents food-borne illness. This has the potential to affect all 35 residents living in the Facility. Findings include: On 10/8/24 at 8:05 AM, in the dry storage room, V6, Dietary Aid, was unloading boxes of food and breaking down boxes. He stated the shipment just came in. He stated he was unsure what to do if cans would ever come in dented. In the dry storage room refrigerator, there was a box of uncooked bacon on the second shelf that was stored directly above lettuce, cucumber and tomatoes. There was a sealed package of deli meat that was dated 9/3 in black marker, but was not labeled. On 10/8/24 at 8:08 AM, the storage room deep freezer contained a bag of poultry that was dated 9/26 in black marker, but was not labeled. There were three packages of meat patties dated 10/8 in black marker that were not labeled. There was a sealed package of deli meat labeled 9/3 that was not labeled. There was a large plastic bag of breadsticks and a large…

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 an ongoing infection control program that adequately collects data to calculate and analyze infection rates. This has the potential to affect all 35 residents living in the Facility. Findings include: The Facility's Infection Control Log for the month of March 2024 does not document a causative organism for R7's infection or R7's type of infection. The Facility's Infection Control Log for the month of August 2024 documents proph (prophylactic) as the cause for R21's RLE (right lower extremity) infection. The Facility's Infection Control Log for the month of July 2024 does not document a causative organism for R31's UTI (Urinary Tract Infection). The Facility's Infection Control Log for the month of February 2024 does not document a causative organism for R91's UTI. On 10/10/24 at 10:17 AM, V3, Infection Preventionist (IP), stated not all of the Facility infections have cultures, and if there is no culture she is not going to know what kind of organism they have. On 10/11/24 at 8:48 AM, V1, Administrator in Training…

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, observation, and record review, the Facility failed to ensure food was prepared in a form to meet residents individual needs for 4 of 4 residents (R8, R9, R11, R13) reviewed for modified diets in the sample of 27. Findings include: On 10/8/24 at 8:20 AM, V7, Dietary Aid, was plating food from the steam table during breakfast service. Food items being served from the steam table were scrambled eggs, ham slices, ground ham, toast, and grits. 1-R8's Face Sheet documents R8 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis, and unspecified dementia. R8's Physician Orders for the month of October 2024 document R8 is on a mechanical soft diet. On 10/8/24 at 8:24 AM V7, Dietary Aid, made a plate for R8 with ground ham. V7 did not add gravy or sauce to moisten the mechanically altered meat. 2-R9's Face Sheet documents R9 was admitted to the facility on [DATE]. R9's Physician Orders for October 2024 document R9 has Alzheimer's disease and…

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

Based on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 4 of 4 residents reviewed (R7, R21, R31, R91) for antibiotic stewardship in the sample of 27. Findings include: 1-The Facility's Infection Control Log for the month of March 2024 does not document R7's type of infection or the organism causing R7's infection. The log documents R7 was treated with the antibiotic Keflex. R7's Medication Administration Record (MAR) for the month of March 2024 documents R7 received 21 doses of Keflex 500 mg (milligram) tabs. On 10/10/24 at 10:10 AM, V2, Director of Nursing (DON), stated no culture was obtained, and the Nurse Practitioner (NP) went by R7's symptoms of toe redness and warmness. 2-The Facility's Infection Control Log for the month of August 2024 documents proph (prophylactic) as the cause of R21's RLE (right lower extremity) infection. The log documents R21's infection was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to provide appropriate services to prevent significant weight loss for one (R20) in a sample 27. R20's not dated Face Sheet documents R20's medical diagnosis as Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Recurrent, Moderate, Other Frontotemporal Neurocognitive Disorder, Paranoid Schizophrenia, Type 1 Diabetes Mellitus W/O Complications and Unspecified Dementia, Unspecified Severity with other Behavioral Disturbances. R20's Minimum Data Set (MDS) dated [DATE] documents (R20's) Cognitive Skills for Daily for Daily Decision Making is severely impaired and requires feeding assistance. On 10/08/24 04:39 PM V13 sister-n-law of R20 stated R20 lost considerable amount of weight because facility did not place him on diet prescribed by hospital. The Administrator, Director of Nursing and nurses stated the facility did not have someone to perform a swallow test therefore R20 would have to remain on pureed diet. R20 lost 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, interview, and record review, the Facility failed to properly store and label medications and dispose of expired medications for 3 of 3 residents (R11, R14, R23) reviewed for medication storage and labeling in the sample of 27. Findings include: On 10/8/24 at 11:00 AM, the medication cart on the 200 Hall was inspected with V8, Licensed Practical Nurse (LPN). The medication cart contained the following: 1-R11's Insulin Lispro 100 units/mL (milliliter) pen that was not dated upon opening 2-A bottle of Guaifenesin with the label rubbed off, leaving behind only a few letters of a resident's name. V8, LPN, first stated it belonged to R23. She stated, I see the (letter) D and the O .Oh wait, that isn't hers. On 10/8/24 at 11:43 AM, the 200 Hall Medication Room was inspected with V2, Director of Nursing (DON). There was a sign on a cabinet door documenting, No food or drink kept in med room refrigerator. The medication refrigerator inside contained the following: 3-A box of frozen pizza stored above four boxes of R11's Arformoterol 15 mcg (micrograms)/2 mL solution.…

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 prevent abuse for 3 of 3 residents (R2, R5 and R8) reviewed for abuse in the sample of 14. This failure placed these residents at risk for physical and psychological harm. Findings include: 1. On 9/3/24 at 10:30 AM V1, Administrator provided two reportable incidents of resident-to-resident physical altercations with the perpetrator in both incidents identified as R5. R5s Undated face sheet documented R5 was admitted to the facility on [DATE] with diagnoses of schizophrenia, depression, legally blind, HTN, Parkinson's disease, tardive dyskinesia, learning disorder, dementia with behaviors, severe alcohol abuse, hepatic steatosis, HLD and diabetes. R5's Minimum Data Set (MDS) dated [DATE] documents R5 is moderately cognitively impaired, experiences hallucinations, requires a w/c for mobility, and requires substantial assist with ADLs. This assessment also documents R5 is always continent of bowel and bladder. R5's care plan dated 6/22/2023 documents:…

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 roof damage was being repaired and fixed to prevent future leaking of water in the facility. This has the potential to affect all 34 residents living in the facility. Findings include: On 8/6/2024 at 11:42 AM, V1, Administrator stated, We have a flat roof and when it rains there are some rooms that leak. We put buckets out and we do not have any residents living in those rooms. We do need a new roof. I have not been asked to get any bids for the repair of the roof. It was especially bad this last storm that we had. We have four rooms currently, they are not occupied because the rooms leak when it is raining. We are in the process of selling the facility and may have a potential buyer. I am hoping for a new roof soon. On 8/6/2024 at 11:43 AM, There were eleven tiles in the ceiling in the dining room with round brown rings/discolored from water damage. On 8/6/2024 at 11:49 AM, room [ROOM NUMBER] was empty with no residents. The ceiling had one tile…

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

Based on observation, interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility. This failure has the potential to affect all 44 residents living in the facility. Findings include: On 2/21/2024 at 8:40 AM, Staffing schedules were requested from the facility for the past 14 days. No RN or Director of Nursing (DON) was observed working in the facility on 2/21/2024 during the day shift. The DON's office was empty, and surveyor was asked to use the office. On 2/21/2024 at 10:33 AM, the staffing schedule provided by the facility does not document RN coverage every day, for 8 consecutive hours for the past 14 days. The staffing schedule does not document any RN coverage for the past 14 days. On 2/21/2024 at 12:42 PM, V1, Administrator stated, I do not have a RN working in the facility. I do not have a full time DON either. I have no RN coverage. The Facility Assessment, dated July 2023, documents, (Facility) is a 94 bed Skilled Nursing Facility set in (Town). DON, 1 DON RN full time Days, if has other responsibilities, add x more RN 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 ensure a qualified and licensed Administrator was certified in accordance with applicable State laws for overseeing the daily operations of the facility. This has the potential to affect all 44 residents living in the facility. Findings include: During this survey no Administrator temporary license and/or Administration license was being displayed in the facility. On 2/21/2024 at 8:77 AM, V1, Administrator stated, I took over as the Administrator back in June after (V10, Former Administrator) left. I do not have my license, but I have applied for a temporary license. I was working here as an agency nurse (LPN) before that. I do not have my temporary license, but I have applied for my temporary license. I am not in contact with (V10, Former Administrator). (V12, Corporate) is overseeing my work as I wait for my temporary license to arrive. I applied but have not yet received it. I applied back in September 2023. V1's Application for Licensure and/or examination was dated 9/12/23. Verification of Employment…

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 treatment was being completed for 1 of 3 residents (R2) reviewed for wound care in the sample of 7. Finding include: R2's Physician Order Sheet (POS) for [DATE] documents a diagnosis of Subarachnoid Hemorrhage, Moderate malnutrition, gross hematuria, and a history of seizures. R2's Minimum Data Set (MDS) dated [DATE] documents R2 was severely impaired for cognition. For bed mobility R2 was total dependence on staff for transfer, dressing, toilet and personal hygiene. R2's Care Plan documents he was high risk for pressure ulcer and staff was to prevent skin area from prolonged contact and his bilateral heels, hips and R2 was not to have bone to bone contact. On [DATE] at 9:20 AM, V5, Family of R2, stated her husband (R2) was no longer in the facility and had died on [DATE]. R2 stated, While he was in the facility, he had an open sore between his toes on his right foot, which had the whole room and hallway smelling and a sore on same foot. I would…

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

Based on observation, interview, and record review, the facility failed to provide services of a Registered Nurse (RN) for at least eight hours daily seven days per week. This has the potential to affect all 42 residents living in the Facility. Findings include: The Facility's Schedule Sheet for nurse staffing was reviewed. The Schedule Sheet does not document the facility had a RN on 12/1/23-12/24/23, 1/2/24, 1/4/24-1/6/23, or 1/8/24-1/16/24. On 1/17/24 at 9:38 AM, V7, Licensed Practical Nurse (LPN), stated V2, Previous Director of Nursing (DON), was a RN, but she is no longer working here. On 1/17/24 at 11:20 AM, V1, Administrator, stated they have been trying to hire RN's but have not had applicants. V1 stated the facility does not have a policy regarding RN staffing, and they just follow the regulations. The Facility's Resident Census and Conditions of Residents Form (CMS 672) dated 1/17/24, documents there are 42 residents living in the Facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to investigate an allegation of abuse for 3 of 7 residents (R1, R5 and R7) reviewed for investigation of abuse allegations in the sample of 7. Finding include: R1's Physician Order Sheet (POS) for November 2023 document a diagnosis of Paroxysmal atrial flutter, essential hypertension, CHF, frequent falls, ETOH (ethanol) Abuse, hyponatremia, Korsakoff disease. R1's POS also documents Outside privileges with medications, including therapeutic overnight, visits with family. R1's Care Plan with a started date of 5/15/2023 documents, Resident has risk factors that require monitoring and interventions to reduce potential for self-injury. Risk factors include Use of a psychotropic medication, HTN and CHF. R1's Minimum Data Set, dated [DATE] document R1 was cognitively intact for decision making of activities of daily living. Resident Council Meeting Minutes dated [DATE], documents, (R1) is a bully and cusses residents out, also comes back drunk at night time and…

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

Based on observation, interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility on the weekends. This failure has the potential to affect all 44 residents living in the facility. Findings include: On 9/26/2023 at 8:10 AM, Staffing schedules were requested from the facility for the past 14 days. On 9/26/2023 at 9:15 AM, V3, MDS/Care Plan Coordinator stated (V2) works full time but she never comes in on the weekends to work. On 9/26/2023 at 10:13 AM, the staffing scheduled provided by the facility document RN coverage every day, for 8 consecutive hours for the past 14 days. On 9/26/2023 at 10:25 AM, V5's (Registered Nurse/Corporate) timecards were requested for Registered Nurse (RN) coverage for the weekends on 9/2/2023, 9/3/2023. 9/9/2023 and 9/10/2023. On 9/26/2023 at 9:29 AM, V1, Administrator stated (V5, RN) was corporate and she did not have any timecard or information to verify that (V5) worked those days. (V5) was documented as working every weekend. (V5) was not working in the facility during the survey. On 9/26/2023 at 9:03…

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 food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 44 residents living in the facility. Findings include: 09/26/23 8:13 AM, a tour of the kitchen was completed. In the main fridge, in the kitchen, there were two 8-ounce bowls of a red substance inside of the bowl. The bowl was not labeled and there was no date. On 9/26/2023 at 8:15 AM, inside the main refrigerator unit there was a large industrial white bowl full of a meat-like substance that was not dated or labeled. There was a full food tray that contained cups of fruit cocktail in 4-ounce bowls that was not covered or dated and exposed to the air. There was also an 8-ounce bowl of green gelatin that was not labeled or dated or covered and was exposed to the air inside the unit. On 9/26/2023 at 8:18 AM, in the refrigerator unit by the ice machine was a box of pizza, that was half eaten and there was no date and/or label, or resident name. The pizza was not covered, and the box was…

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

Based on interview and record review the facility failed to adequately develop an ongoing Infection Control Program that adequately collects data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 44 residents living in the facility. Findings Include: R146 was documented on the Facility Infection Control Log for the month of August 2023. Date of onset 8/9/2023 and date resolved 8/11/2023 from hospital. The log documents, R146 had a UTI, (urinary tract infection). R146 returned from the hospital taking Cefdinir 300 milligrams, 1 capsule by mouth two times a day for 2 days. The Infection Control Log for the month of August 2023 does not document the organism causing the UTI. On 9/26/2023 at 10:00 AM, the Culture and Sensitivity Report, (C & S), was requested for 8/9/2023 and no Culture and Sensitivity Report was provided and no organism from the hospital was documented for R146 on the infection control log. No organism was documented in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were eating in a homelike environment and not served food on Styrofoam containers with plastic utensils for 4 of 4 residents (R11, R29, R34, and R42) reviewed for accommodations of needs in the sample of 24. Findings include: On 9/26/2023 at 12:00 PM, On the hall tray cart containing the hall room trays, all the food was being served in Styrofoam containers that closed and with plastic silverware. On 9/27/2023 at 12:05 PM, On the hall tray cart containing the hall room trays, all the food was being served in Styrofoam containers that closed and with plastic silverware. 1-R34's Minimum Data Set, (MDS), dated [DATE] document, she is cognitively intact for decision making of activities of daily living, (ADL's). 09/27/23 12:39 PM R34 stated, I am the president for Resident Council and anybody that gets a hall tray is served their food on Styrofoam to go containers with plastic utensils. These containers do not keep the food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician and/or nurse practitioner in a change in condition for 1 of 1 resident (R95) reviewed for change in condition in the sample of 24. Findings include: R95's Face Sheet documents he was admitted to the facility on [DATE]. R95's Cumulative Diagnosis Log, undated, documents, his diagnoses as: Ortho Aftercare (right hip fracture post-surgery); Gastrointestinal Bleed, (GI Bleed); Reduced Mobility-Activities of Daily Living Deficit; Gout; Wound Surgical Site Care; and Gastroesophageal Reflux Disease, (GERD). R95's Nurse's Notes dated 9/17/23 at 5:00 PM documents, Resident quiet today, no complaint of discomfort. Had some blood in his stool this morning, but no more today. Need to let (V18, Nurse Practitioner, (NP),) know, when possible, on Wednesday. Resident is resting in bed, call light nearby. Yet waiting on meds to come into the facility. R95's Nurse's Notes dated 9/18/23 at 6:00 PM documents, CNA, (Certified Nursing Assistant),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to maintain a clean, comfortable environment for 3 of 4 residents (R1, R2 and R34) reviewed for poor housekeeping services in the sample of 24. Findings include: 1. On 9/26/23 at 9:48 AM R34 stated, they clean her room daily during the week but not on the weekends, they empty the trash but don't clean the room. V34 stated, the trash is left out in the hallway on the weekends. V34 stated it's depressing, the walls are all marked up and icky. R34's room was observed with the following noted: paint peeling, holes in the walls, floor dirty against the baseboards, windowsill dusty and dirty, bathroom floor has a black substance behind toilet and the toilet seat was dirty. R34's Minimum Data Set, (MDS), dated [DATE], documents R34 is cognitively intact. 2. On 9/26/23 at 10:21 AM R1 stated, he is blind and can't see if his room is dirty or not. R1 stated, he doesn't know if housekeeping is cleaning his room unless they tell him. R1's room was…

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

Based on interview and record review the facility failed perform antibiotic stewardship for one of three residents (R26, R27, R146, R147,) reviewed for antibiotic stewardship in the sample of 24. Findings Include: 1-R146 was documented, on the Facility Infection Control Log for the month of August 2023. The log documents R146 had a UTI, (urinary tract infection). R145 returned from the hospital taking Cefdinir 300 milligrams, 1 capsule my mouth two times a day for 2 days. On 9/26/2023 at 10:00 AM, the Culture and Sensitivity Report, (C&S), was requested for R146 for 8/9/2023 and no Culture and Sensitivity Report was provided. No documentation was provided documenting Cefdinir was effective for the urinary tract infection on 8/9/2023. R146 was documented, on the Facility Infection Control Log for the month of August 2023. Date of onset 8/15/2023, (six days later), and date resolved 8/22/2023 for Urinary Tract Infection. No Culture and Sensitivity Report was provided by the facility to review for 8/15/2023. R146 was given Cipro 500 milligrams (mg), 1 tablet by mouth two times a day…

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 use the services of a Registered Nurse, (RN), for at least eight hours daily. This has the potential to affect all 49 residents living in the facility. Findings Include: The Facility's Schedule Sheet for RN, (Registered Nurse), and LPN, (Licensed Practical Nurse), hours scheduled was provided for 07/01/23 through 08/31/23. These document the facility did not have a RN for eight hours from 07/01/23 through 07/22/23, 07/24/23 through 07/31/23, 08/05/23, 08/06/23, 08/13/23, 08/19/23, or 08/20/23. On 08/22/23 at 10:45 AM, V1, Administrator, stated, she has not had RN coverage every day. On 08/22/23 at 10:58 AM, V4, Licensed Practical Nurse, (LPN), stated, there are several RN's who fill in at the facility, but there is no stable RN for five or seven days a week. On 08/22/23 at 11:10 AM, V1, Administrator, stated, the facility does not have a policy for RN Staffing, and they follow the State Regulations. The Facility's Resident Census and Conditions Form (CMS 672), dated 08/22/23 documents, there are 49 residents living in the…

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

Based on interview and record review, the facility failed to investigate an allegation of abuse in 3 of 5 residents (R1, R2, R3) in the sample of 27 and failed to protect residents from further abuse by failing to remove the accused employee from resident contact. The failure had the potential to affect 26 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27) on the 200 Hall. Findings Include: 1-R1's Nurse's Note by V4, LPN, dated 07/02/23 at 8:30 AM documents, Pt was aggressor in a physical confrontation with another resident. NP notified. R1's Care Plan dated 07/02/23 documents, Pt aggressive with another resident. No physical contact was made. Staff separated residents. Sent to ER, (Emergency Room), for evaluation per hall nurse. On 08/22/23 at 9:00 AM, V1, Administrator, stated, she was not aware of the incident when R1 tried to stab R3 with a fork during meal time. On 08/22/23 at 1:25 PM, V1, Administrator, stated, I was made aware that evening. They were separated, and no physical contact had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from abuse in 2 of 5 residents (R1, R3) reviewed for abuse in the sample of 27. Findings include: The Facility's Resident Council Meeting Minutes dated, 7/3/23 document, (R1) is violent, she tried to stab (R3) with a fork during meal time. We do not feel safe with (R1) at meals. 1-On 8/22/23 at 10:02 AM, R1 was propelling herself down hallway in wheelchair. She stated, she feels safe in the facility and did not recall the incident with R3. R1's Face Sheet documents, R1 was admitted to the facility on [DATE]. R1's Care Plan documents, diagnoses including altered mental status; heart failure; major depressive disorder, recurrent, moderate; chronic obstructive pulmonary disease; and essential primary hypertension. R1's Minimum Data Set, (MDS), dated [DATE] documented, R1 was severely cognitively impaired, independent with ambulation, and had no physical or verbal behavioral symptoms directed at others. R1's Nurse's Note by V4,…

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

Based on interview and record review, the facility failed to report allegations of abuse to Illinois Department of Public Health, (IDPH), per regulations and allowing an employee to work several consecutive shifts, for 3 of 5 residents (R1, R2, R3) reviewed for reporting of abuse in the sample of 27. Findings Include: 1-R1's Care Plan dated 07/02/23 documents, Pt, (Patient), aggressive with another resident. No physical contact was made. R1's Nurse's Note by, V4, Licensed Practical Nurse, (LPN), dated 07/02/23 at 8:30 AM documents, Pt was aggressor in a physical confrontation with another resident. On 08/22/23 at 9:15 AM, V4, LPN, stated, (R1) attempted to - was going after somebody with a fork. There was no contact made and no injuries. The other person was (R3). I'm not sure if I reported it to (V1). I think I did. I know I notified the Doctor. On 08/22/23 at 9:00 AM, V1, Administrator, stated, she was not aware of the altercation between R1 and R3 with a fork during meal time and therefore did not report it to IDPH. On 08/22/23 at 1:25 AM, V1, Administrator, stated, I was made…

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

Based on observation, interview, and record review, the facility failed to follow pest control recommendations to effectively control pests in the facility. This has the potential to affect all 49 residents living in the Facility. Findings include: On 8/1/23 at 8:40 AM there was a centipede measuring approximately two inches long on the wall of the main dining room. On 8/1/23 at 8:45 AM there were two bags of garbage stored directly on the floor next to Door 6. On 8/1/23 at 8:46 AM in the food storage room there were six cardboard boxes containing sausage and hamburger patties that was stored directly on the floor. There was also a package of six industrial size cans stored directly on the floor. On 8/1/23 at 8:50 AM in the laundry room there was a hole near the bottom of the wall measuring approximately four by eight inches. On 8/1/23 at 9:04 AM the entry to the Doctor's Lounge on the 100-Hallway had a brown sticky area on the tile that measured approximately six by twelve inches. On 8/1/23 at 9:17 AM there was a fly swarming down the 200-hallway to the right of the main entrance.…

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 that floors, walls, ceilings, air conditioning units, and shower rooms were maintained in clean and good repair for 4 of 4 residents (R1, R3, R4, and R5) reviewed for clean, comfortable, and homelike environment in the sample of 11. Findings include: 1. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact. On 8/1/23 at 8:27 AM, R1 stated the facility is not always kept as clean as it should be. R1 stated some housekeepers just take out the trash and do not clean anything else. On 8/1/23 at 8:27 AM, the edges of R1's floor were visibly dirty, and dust covered, and there was dust and dirt covering the exterior of the air conditioner. 2. R3's MDS dated [DATE] documented R3 was cognitively intact. On 8/1/23 at 10:10 AM, R3 stated he has to stay on top of them about cleaning. R3 stated nobody is cleaning the shower room, and there is mold all over it and in between the cracks. R3 stated there is so much dust 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.