Arcadia Care Toulon

Based on observation, interview, and record review, the facility failed to maintain or repair residents' missing and peeling wall coverings and exposed dry wall for 8 residents (R13, R16, R31, R39, R42, R44, R62, R69), and failed to repair the wall area between the HVAC/heating, ventilation, air-conditioning unit and the window sill for two residents (R30, R37) in the total sample of 41 residents reviewed for clean, comfortable and homelike environments. This failure has to potential to affect all 67 residents living in the facility Findings include: The facility room roster, dated 2/24/26, documents 67 residents reside in the facility.The facility's Maintenance Director Job Description, dated 03/2024, documents The primary purpose of the Maintenance director is to plan, organize, develop, and direct the overall operation of the Maintenance in accordance with current federal, state and local standards, guidelines, and regulations governing our facility., and Essential Duties and Responsibilities: Repair facility/resident property as necessary. In the event of inability to repair,…

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

Based on record review and interview, the facility failed to ensure all staff received mandatory training and education for infection prevention and control. This failure has the potential to affect all 67 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 2/24/26, were reviewed. The Census Roster documented 67 residents resided in the facility.The facility's Facility Assessment Tool for (facility) 11/1/2025-11/1/2026, dated 12/9/25, documents, Staff training/education and competencies: see Healthcare Academy (online education platform). Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program.On 3/3/26 at 11:00 AM, V1/Administrator stated she did not have documentation demonstrating staff employed at the facility received the required staff training/education and competencies. V1 stated she reviewed the reports for the required education in the online education platform 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 record review and interview the facility failed to ensure all staff were provided education, in-services, and training regarding the facility's standards, policies, and procedures for Compliance and Ethics. This failure has the potential to affect all 67 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 2/24/26, were reviewed. The Census Roster documented 67 residents resided in the facility.The facility's Facility Assessment Tool for (facility) 11/1/2025-11/1/2026, dated 12/9/25, documents, Staff training/education and competencies: See Healthcare Academy (online education platform) to include but not limited to: communication; residents' rights and facility responsibilities; abuse, neglect, and exploitation; infection control; culture change; identification of resident changes in condition; and cultural competency. Consider the following competencies (this is not an inclusive list): person-centered care, activities of daily living, disaster planning and procedures, infection control, medication…

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 Certified Nursing Assistants (CNAs) were provided and completed a minimum of 12 hours of inservice training per year. This failure has the potential to affect all 67 residents residing in the facility. Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 2/24/26, were reviewed. The Census Roster documented 67 residents resided in the facility.The facility's Facility Assessment Tool for (facility) 11/1/2025-11/1/2026, dated 12/9/25, documents, Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year; Include dementia management training and resident abuse prevention training; Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by facility staff; For nurse aides providing services to individuals with cognitive impairments, also address the care of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide a Pneumococcal Immunization to two residents (R1, R60) that requested to receive it and failed to offer a Pneumococcal Immunization to three (R13, R52, R55) residents out of 8 residents reviewed for immunizations, in a sample of 41.Findings include: The facility's Influenza and Pneumococcal Immunizations Policy dated 12/2025 documents: Each resident is offered a pneumococcal immunization. The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident either received or did not receive the pneumococcal immunization due to medical contraindications or refusal. On 2/25/2026 at 1:00 PM, V3 (ADON/Infection Preventionist) reported a pneumococcal immunization clinic was held at the facility on 12/01/2025. 1. R1's medical record documents R1 was admitted to the facility 09/12/2025 with diagnoses to include Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Diabetes,…

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 treat three residents (R5, R27,R76) with dignity in three reviewed for dignity in a total sample of 41.1. R5's medical record documents R5 was admitted to the facility on [DATE] with diagnoses to include Spina Bifida, Paraplegia, Chronic Obstructive Pulmonary Disorder, Hydronephrosis, and Urinary Retention. On 2/25/26 at 2:15 PM, V11 (Certified Nurse Aide/CNA) and V16 (CNA) transferred R5 via mechanical lift from his wheelchair to his bed. R5's privacy curtain was not pulled prior to V11 and V16 pulling down his pants and incontinent brief to prepare him for catheter procedure. V18 (Licensed Practical Nurse/LPN) entered room and pulled the privacy curtain between R5 and his roommate. 2. R27's medical record documents R27 was admitted to the facility on [DATE] with diagnoses to include Paraplegia, Hypothyroidism, Coarctation of Aorta, Viral Hepatitis C and Arthritis. On 2/25/26 at 2:30 PM, R27 was in his room with the door open. V18 (LPN)…

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

Based on observation, interview and record review, the facility failed to ensure a resident's toileting preferences and needs were reasonably accommodated for one of one resident (R51) reviewed for accommodation of needs in a sample of 41. Findings include:The facility's Facility Assessment Tool for (facility) 11/1/2025-11/1/2026, dated 12/9/2025, documents under Part 3: Services and Care Based on Residents Needs, Find out what resident's preferences and routines are; incorporate this information into the care planning process. Make sure staff caring for the resident have this information. Record and discuss treatment and care preferences.R51's MDS (Minimum Data Set) assessment, dated 2/10/2026, documents in Section A an admission date of 4/17/2015; Section I documents R51 has Alzheimer's Disease, Non-Alzheimer's Dementia, and Parkinson's Disease; Section GG documents R51 is dependent on staff for transfers and all Activities of Daily Living (ADLs); and Section C documents R51 is rarely/never understood and no Brief Interview for Mental Status (BIMS) completed due to inability to…

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

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, and comfortable environment for four of 24 residents (R1, R48, R58, R60) reviewed for a homelike environment in a sample of 41. These failures have the potential to affect all 67 residents residing within the facility.Findings include:The facility's Housekeeper Job Description Summary documents the primary purpose of the Housekeeper is to perform day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Environmental Services, to assure that our facility is maintained in a clean, safe, and comfortable manner. The essential duties and responsibilities include but are not limited to ensuring work/cleaning schedules are followed as closely as practical and cleaning floors including, sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting, etc. The facility's Maintenance Director Job Description…

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 1 of 1 resident (R9) reviewed for physical restraints was free from physical restraint, in a sample of 41. Findings include:The facility's Restraint Policy dated 12/2025 documents the definition of a physical restraint includes self release belts if the resident is physically incapable of releasing the belt.The facility's Restraint Policy dated 12/2025 documents:Guidelines:Residents that are admitted with a Physician's order for restraint use shall have a restraint use assessment performed and a physician order obtained for the release of restraints with supervision during the assessment process, as appropriate, or an order to discontinue use.Periodic assessments shall address the resident's status in an effort to reduce or eliminate restraints whenever possible and assure the restrictive method is used which allows the resident to function at their highest practicable level.The use of restraints will be reviewed by 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 have appropriate indications for use for psychotropic medications for three of five residents (R6, R7, R11) reviewed for unnecessary medications in a sample of forty-one.Findings include: The Facility's Gradual Dose Reduction policy dated 2/2018, documents the purpose of the policy is to ensure that residents are not given psychotropic drugs unless psychotropic drug therapy is necessary to treat a specific or suspected condition as per current standards of practice, and are prescribed at lowest therapeutic dose to treat such conditions. R6's Medical Record documents she was admitted to the facility on [DATE] with diagnosis to include but not limited to Metabolic Encephalopathy, Severe Dementia and Unspecified Mood Disorder. R6's Physician Order Sheet dated February 2026 documents, R6 receives Depakote Sprinkles (medication approved for use of Bipolar Mania) 250 mg (milligrams) twice a day for Dementia with Anxiety and Seroquel…

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 document discharge status for one resident of two residents (R71) reviewed for discharge in a sample of forty-one.Findings include:The Facility's Notice of Transfer and Discharge policy dated 10/2022 documents When the facility transfers or discharges a resident under any of the circumstances specified in reasons A through F above, the facility must ensure that the transfer or discharge is documented in the residents medical record and appropriate information is communicated to the receiving health care institution or provider. R71's Medical Record documents that he admitted to the facility on [DATE] with diagnosis to include cellulitis to both legs and need for assistance with wound care with a plan to go back home after legs were healed. R71's Medical Record documents that the wound doctor came to the facility on [DATE] and sent R71 to the emergency room for evaluation of wounds. R71's Medical Record does not document any further information…

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 update a care plan after an incident for one resident of twenty-four residents (R7) reviewed for care plans in a total sample of forty-one.Findings include:The Facility's Comprehensive Care Plan policy dated 1/2026, documents that each resident should have a comprehensive plan of care. The policy documents the care plan should be revised on an ongoing basis to reflect changes in the resident and the care the resident is receiving. R7's Medical Record documents that she was admitted to the facility on [DATE] with diagnosis to include but not limited to Dementia, Depression and Hypertension. R7's Nurse's Note documents on 2/12/26, R7 fell in her room. The documentation shows that R7 has a refrigerator in her room and she was attempting to get something out of the freezer and she hit herself in the head with the door and fell to the ground with no injuries. The Nurse's Note documents New Intervention: encourage resident to ask for assistance with 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 record review and interview, the facility failed to have supporting documentation for diagnosis for two of twenty-four residents (R10, R11) reviewed for justified diagnoses, in a total sample of forty-one.Findings include: 1. R10 was admitted on [DATE] with diagnosis of Post Traumatic Stress Disorder and Generalized Anxiety. The Brief Interview for Mental Status (BIMS) documents on 1/29/26, R10's cognition was moderately impaired and from 2/3/26 to present has been cognitively intact. The Preadmission Screening and Resident Review Level 1 dated 1/27/26, documents R10 did not have a Dementia or Alzheimer's Disease Diagnosis, and a Level 2 assessment was not required. V56's (R10's Family Physician) visit notes dated 12/30/25, 10/31/25 and 8/22/25, documents R10 had been evaluated for Dementia and passed the given test. No diagnosis of Dementia or Alzheimer's Disease were identified on the visit notes. R10's Elopement/Unauthorized Leave Risk review dated 1/29/26, documents R10 has a . history of or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assist and provide showers for three of twenty-four residents (R6, R43, R48) reviewed for showers, in a total sample of forty-one. Findings include: The Resident Council Meeting Minutes dated 1/7/26 documents residents still not getting showers. 1. R6's Medical Record documents he was admitted on [DATE] with diagnosis to include but not limited to Chronic Obstructive Pulmonary Disease (COPD), Type II Diabetes Mellitus and Right Lower Leg Cellulitis. R6's MDS (Minimum Data Set) dated 11/25/25 documents that he needs Partial/Moderate assistance with showering and bathing. On 2/24/26 at 10:16 AM, R6 was sitting in his recliner, hair appeared disheveled, was in just shorts, fingernails were long and jagged and he had facial hair. R6 stated he has been at the facility for approximately a year and has only had 5 showers. R6's admission was on 8/14/25 and first shower sheet noted was on 10/21/25 and states that resident gave himself a sponge…

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 assess, develop and implement a care plan and provide an ongoing program of activities based on residents' assessments and preferences for 2 of 4 residents (R51, R11) reviewed for activities in a sample of 41.Findings include:Findings include: The facility's Activities Program Policy, dated 1/2026, documents the purpose of the Activities Program is to provide an ongoing program of activities designed to appeal to the residents' interests and to enhance his or her highest practicable level of physical, mental, and psychosocial well-being. The guidelines outlined in this same policy document: the Activity Director, trained staff, or volunteer will: 1. Identify and involve each resident in an ongoing program of activities that is designed to appeal to his or her interests and needs, and 2. Enhance the resident's highest practicable level of physical, mental, and psychosocial well-being by offering a program of activities that provides 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 interview and record review, the facility failed to do a urinary voiding trial as ordered for one of four residents (R8) reviewed for indwelling catheters, in a total sample of forty-one. Findings include:The Facility's Bowel and Bladder-Assessment and Toileting Programs policy dated 1/2026 documents The CNAs (Certified Nurse Aide) will document incontinent episodes on the Voiding Diary for 3 days as assigned. The incontinence data will be reviewed to try to identify a resident voiding pattern. The Restorative Incontinence Observation will be completed and an Incontinence/Toileting Program will be implemented based on the resident data and assessment as deemed appropriate. The resident's plan of care will be developed to address the issue(s), goals and appropriate interventions for elimination program, using an interdisciplinary team approach.R8's Medical Record documents that she was readmitted to the facility on [DATE] after a short hospitalization for Influenza and a Urinary Tract Infection. R8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews and observation, the facility failed to ensure oxygen tubing was changed routinely for one of one resident (R55) reviewed for respiratory care, in a sample of 41.Findings include:The facility's Oxygen and Respiratory Equipment-Changing/Cleaning Policy dated 12/2025, documents nasal cannulas are to be changed weekly and as needed. R55's medical record documents R55 was admitted to the facility on [DATE] with diagnoses to include but not limited to: Chronic Obstructive Pulmonary Disease, Diabetes, Venous Insufficiency, Polyneuropathy, and Schizophrenia. R55's Physician Order dated 11/26/25, documents to change oxygen tubing weekly and as needed. On 02/24/26 at 9:48 AM, R55 was lying in bed with oxygen on at 2 liters via nasal cannula. R55's nasal cannula tubing was dated 02/14/2026 and the prefilled humidification bottle was dry and dated 02/14/26. R55 states I've asked to get that filled for two days, but they haven't done it and my nose is starting to dry out. On 02/24/2026 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were safely administered for one of seven residents (R48) observed during the medication administration pass, in a sample of 41. Findings include:The Medication Administration policy, revised 4/22, documents Licensed Nurses may prepare, administer and record the administration of medications with the date, time and initials of the staff member who administered the medication; that residents may self-administer medication if the interdisciplinary team has determined that this is safe; Medications must be administered in accordance with physician's order to the right resident, right medication, right dose, right route and right time.R48 was admitted on [DATE] with diagnoses of Posthemorrhagic Anemia, Malignant Neoplasm of Cervix, Ovary and Uterus and Cerebral Vascular Infarct.R48's current care plan does not indicate R48 can self-administer medications. R48's record did not include a Physician's Order to self-administer…

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 a resident from physical abuse by another resident for one (R3) of 5 residents reviewed for physical abuse by another resident in the sample of 8 residents reviewed for abuse. This failure has the potential to affect all 18 residents currently living in the Memory Care Unit on E Hall. Findings include: On 11/4/25 the facility notified the state agency of a resident to resident physical altercation incident that had allegedly occurred between R2 and R3 on 11/4/25 at 11:30am in the Memory Care Unit.The facility's Abuse Prevention and Reporting - Illinois policy dated 12/2025 documents the following: this facility affirms the right of our residents to be free from abuse. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment.R2's medical record documents R2 is 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 ensure a resident was free from abuse when R2 was deprived of utilizing a jacket for one of three residents (R2), reviewed for abuse in a sample of 5.FINDINGS INCLUDE:The facility's Abuse Prevention and Reporting- Illinois policy, dated 11/2016, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The policy also documents, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain…

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 an allegation of abuse was immediately reported to the Administrator and the State Agency for one of three residents (R2) reviewed for abuse in the sample of 5.FINDINGS INCLUDE:The facility's Abuse Prevention and Reporting- Illinois policy, dated 11/2016, documents Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must immediately report it to the administrator. The policy also documents, Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Department of Public Health immediately, but no more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.A facility Concern/Compliment Form, dated 7/18/2025, documents, Nature of concern, 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 investigate an allegation of potential abuse for one of three residents (R2) reviewed for abuse, in the sample of 5.FINDINGS INCLUDE:The facility's Abuse Prevention and Reporting- Illinois policy, dated 11/2016, documents, Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in an investigation.A facility Concern/Compliment Form, dated 7/18/2025, documents, Nature of concern, on 6/15/2025, V19/R2's family and V7/R2's Power of Attorney were visiting (R2) and noticed (R2) didn't have his jacket on. (R2) was asking where his jacket was because (R2) was cold. V7 says (R2) lived with her for 8 years prior to nursing home placement, and (R2) always wore a jacket around the house. V6/Certified Nursing Assistant informed V19 and V7 that she took (R2's) jacket from him because (R2) wanted to leave the facility and was having exit seeking behaviors. V6 informed V19 and V7 that she hung (R2's) jacket in the shower room and wasn't going to give it back.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 use a full mechanical lift for 3 (R1, R4, R5) residents who require a full mechanical lift for transfers in a sample of 22. Findings include:The facility's policy titled Incident and Accidents-Illinois, effective 10/2024, documents not in its entirety, An 'incident' is defined as any happening, not consistent with the routine operation of the facility, that does not result in bodily or property damage. Physical or mental mistreatment (abuse-actual or suspected) of a resident is considered an 'incident' whether or not actual injury has occurred. An 'accident' is defined as any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. The facility's policy titled Transfers-Manual Gait Belt and Mechanical Lifts, effective 4/2025, documents not in its entirety, In order to protect the safety of the Staff and Residents, and to promote quality care, this facility will use Mechanical…

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 thoroughly assess and document an accurate assessment for one resident (R1) transferred to the emergency room of three residents reviewed for hospitalizations in a total sample of thirteen. Findings Include: The Facility's Assessment of Resident policy dated 10/2024 documents the purpose of the policy is to gather comprehensive information as a basis for identifying resident problems/needs and developing or revising an individual plan of care. The policy also documents begin assessment based on resident position. Conduct head to toe examination on admission incidents, and significant status changes and periodically as necessary. Conduct specific system assessment, as required by the diagnosis, history or physical complaint. If reassessing resident, review previous nursing progress notes, physician's orders and progress notes, weights, intake/output records laboratory test results, resident's response to current treatments. Document resident comments, complaints as appropriate and assessment findings in the nursing progress…

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

Based on observation, interview and record review the facility failed to have fall interventions in place for one resident (R3) of three residents reviewed for falls in a total sample of thirteen. Findings Include: The Facility's Fall Prevention Program dated 5/2022 documents the purpose as to assure the safety of all residents in facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk. R3's Nurse's Notes dated 5/8/25 at 10:30 AM documents The CNA (Certified Nurse Aide) observed (R3) sitting half upright onto the buttock, near the bed. R3's current care plan had an entry dated 5/10/25 Add non-slip material to wheelchair. On 6/20/25 at 1:30 PM R3 was propelling herself in the main dining room area of the facility. R3 did not have any non-slip material to the seat of her wheelchair. V7 (Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician's orders by not obtaining a urine sample as ordered in a timely manner for one of three residents (R3) reviewed for nursing services in a sample of 9. Findings include: R3's electronic record documented admission date of 06/22/2023 with a past medical history not limited to paraplegia, depression, extended spectrum beta lactamase (esbl) resistance, and urine retention. Brief interview for Mental Status (BIMS) assessment dated [DATE] indicated no cognitive impairment. R3's active orders as of 05/14/2025 showed resident is on enhanced barrier precautions for wounds, esbl in urine and straight catheterization (cath); esbl colonized (12/23/2024); infectious disease consult for diagnosis of esbl in urine; straight cath every four hours while awake due to urine retention; may straight cath during the night as needed for distention. R3's care plan report provided by facility on 05/14/2025 reads in part: resident is at risk/actual for urinary…

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

Based on record review and interview, the facility failed to ensure resident grievances are resolved in a timely manner. This failure has the potential to affect all 64 residents living in the facility. Findings include: An undated facility policy titled Resident Grievances/Complaints documents, It is the policy of (this facility) to actively encourage residents and their representatives to voice grievances and complaints on behalf of themselves or others without discrimination or reprisal. Grievances and or complaints may be reported to the Administrator, any staff member, the Resident Advisory Council, the Long Term Care Advisory Board and to State Agencies. All staff are required to report any, and all grievances and complaints received from Residents. The Administrator is responsible to promptly resolve complaints and grievances. The policy further states, 6. The Investigator shall notify the Resident and document the results of the investigation and notification on the grievance/complaint form. The Social Service Director is responsible to notify the family and resident…

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

Based on record review and interview, the facility failed to ensure a Registered Nurse was scheduled for at least eight consecutive hours each day. This failure has the potential to affect all 64 residents living in the facility. Findings include: An undated Nurse Staffing Policy documents, It is the policy of (this facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health. The policy continues, A minimum of 25% (percent) of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time provided by registered nurses. Registered nurses and licensed practical nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. Review of untitled…

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

Based on record review and interview the facility failed to ensure residents were notified that signing an arbitration agreement was not a condition of admission and residents have 30 days to rescind the agreement within 30 days of signing. This failure has the potential to affect all 64 residents in the facility. Findings include: R49's Agreement to Resolve Disputes by Binding Arbitration dated 05/09/23 and R59's Agreement dated 07/06/23 were reviewed. These agreements do not include language which notifies residents that signing the agreement is not a condition of admission and they have the right to refuse. The agreements also do not explicitly grant the resident or their guardian the right to rescind the agreement within 30 calendar days of signing. On 10/31/24 1:45 PM, V4 confirmed the Arbitration Agreements do not contain documentation that signing the agreement is not a condition of admission nor does it say the form can be rescinded within 30 days. The facility's Long Term Care Facility Application for Medicare and Medicaid, dated 10/29/24 and signed by V1 (Administrator)…

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

Based on interview, observation and record review, the facility failed to ensure the QAA/Quality Assessment and Assurance Committee had the required number of Members; failed to ensure the QAA Committee met at least quarterly; and failed to have reports submitted by Infection Preventionist. This failure has the potential to affect all 64 Residents residing at the facility. Findings Include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) form dated 10/29/24 documents 64 residents reside in the facility. The facility's Quality Assurance Plan Dated 8/1/17 documents: (Facility) works to continuously improve the way residents are cared for, safety and operations within the facility through the Quality Assurance process. Quality Assurance activities are to be completed continuously and objectively to provide a comprehensive review of the facility's activities. The Quality Assurance Committee will conduct: Quarterly Meetings (at a minimum). On 10/31/24 at 1:45pm, V1 Administrator stated that (V17 Medical…

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

Based on record review and interview, the facility failed to develop and implement an Antibiotic Stewardship Program to promote the appropriate use of antibiotics and include a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This failure has the potential to affect all 64 residents residing in the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid 10/29/24 documents the facility's census of 64 residents. The facility's Antibiotic Stewardship Program policy, dated 12/12/18 states the following: Purpose: To improve the use of antibiotics in healthcare to protect the residents and reduce threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. R34's Physicians Orders include the following antibiotic order dated 10/18/24: Doxycycline Hyclate Oral Tablet 100 mg (milligrams): Give 100 mg by mouth two times a day for skin wounds until 11/01/2024 16:00/4:00pm for 14 days. R34's…

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

Based on record review and interview, the facility failed to designate an Infection Preventionist (IP) who is responsible for assessing, developing, implementing, monitoring, and managing the Infection Prevention and Control Program and implement programs and activities to prevent and control infections. This has the potential to affect all 64 residents residing in the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid 10/29/24 documents the facility's census of 64 residents. The facility's Infection Control policy dated 12/7/18 documents the following: It is the policy to do routine and surveillance and monitoring to determine if compliance with infection control practices is maintained. The facility shall employ, at a minimum, a part-time Infection Control Preventionist. R34's medical records document R34 is currently receiving Doxycycline, an antibiotic. Physicians Orders document the following order: Doxycycline Hyclate Oral Tablet 100 mg (milligrams). Give 100 mg by mouth two times a day for skin wounds until 11/01/2024…

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 record review, observation and interview, the facility failed to provide influenza vaccine for residents eligible for influenza vaccination during flu season and failed to minimize the risk of acquiring, transmitting and suffering complications from influenza for five of five residents R14, R28, R33, R38, and R45 reviewed for immunizations in the total sample of 22. Findings include: The facility's policy titled Influenza Control Measures dated 10/10/22 documents the following: Influenza Vaccine: 3. Continue to administer the influenza vaccine throughout the influenza season (Upon receipt of the vaccine-March 1). The facility's Infection Control binder includes the IDPH Guidelines for the Prevention and Control of Influenza Outbreaks in Illinois Long Term Care Facilities dated 10/18/21, which documents the following: Long Term Care should implement the following guidelines for vaccinating residents: b. Residents should be vaccinated on an annual basis as soon as influenza vaccine becomes available, unless medically contradicted. R14's Physicians Orders include: May have…

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 PASARR (Pre-admission Screening and Resident Review) screening was completed for one (R28) of five residents reviewed for PASARR screenings in the sample of 22. Findings Include: The Centers for Medicare and Medicaid Services/CMS National Report: A Review of Preadmission Screening and Resident Review (PASARR) Programs Dated 12/2019 documents: Preadmission Screening and Resident Review (PASARR) is a federal Medicaid requirement that mandates states operate programs designed to: (1) identify individuals who might be admitted to or reside in a nursing facility (NF) who have a serious mental illness (SMI), or an intellectual disability or a related condition (ID/RC); (2) consider both NF and community placements for such individuals and recommend NF placement only if appropriate; and (3) identify the PASARR specific needs that must be met for individuals to thrive, whether in a NF or the community. Facility documentation shows that R28 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 record review, and interview, the facility failed to revise care plans for two residents (R2 and R55) of 16 residents reviewed for Care Plan revisions, in a total sample of 22 residents. FINDINGS INCLUDE: Facility policy, entitled Comprehensive Care Planning, revised 7/20/24, document, b. The Care Plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the resident. R2's Electronic Medical Record (EMR) document R2 was placed on hospice services per physician order dated 7/24/2024 and is still receiving hospice services. R2's Care Plan does not include hospice. R55's EMR document R55 has a stage 2 pressure wound on R55's coccyx with wound care orders dated 10/13/2024. R55's Care Plan was not revised to include R55's stage 2 pressure wound. On 10/31/2024, at 9:27 a.m. and 11:55 a.m., V4/Regional Director of Operations confirmed R2 and R55's Care Plans were not revised, and should have been, to include R2's Hospice services and R55's pressure wound.

Based on observation, interview and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for two of five residents (R6, R14) reviewed for unnecessary medications in the sample of 21. Findings include: 1. On 12/1/21 R6 had a diagnosis of Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. On 09/06/24 R6's BIMS/Brief Interview for Mental Status score was 15, indicating R6 is cognitively intact. R6's Care Plan dated 08/21/24 documents behaviors of hoarding and having a history of being paranoid with others including false accusations. R6's 10/17/24 Physician Order Sheet documents an order for Quetiapine (antipsychotic) 50 milligrams to be given with 200 milligram dose totaling 250 milligrams at bedtime related to Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. On 10/31/24 at 10:51 AM, V4/Director of Operations confirmed R6 has an order for Quetiapine 250 milligrams 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 observation, record review and interview the facility failed to ensure its enhanced barrier precautions policy was followed for two of two residents (R1, R24) reviewed for enhanced barrier precautions in a sample of 22. Findings include: A facility Enhanced Barrier Precaution Policy dated 07/13/23 documents, Purpose: to reduce transmission of multidrug-resistant organisms (MDRO). Enhanced Barrier Precautions (EBP) should be used when contact precautions do not apply, for residents with any of the following: open wounds that require a dressing change, indwelling medical devices, infection or colonized with MDRO. Enhanced Barrier Precautions require use of a gown and gloves during high-contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. EBP is primarily intended to use for care that occurs within a resident's room, when high-contact resident care activities are bundled together. 1. R24's October 2024 Physician Order Sheet documents R24 has a supra pubic indwelling catheter and a J-tube (jejunostomy tube). 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 record review and interview, the facility failed to notify a physician per their facility policy of a medication error/omission for one resident (R1) of three residents reviewed for physician notification of changes in a total sample of three residents. Findings include: Policy last reviewed 09/27/17 titled Conformance with Physician Medication Orders Policy documents, (All) medications shall be given as prescribed by the physician and at the designated time. Procedure: 7. The resident's attending physician shall be notified of medications about to be stopped so the physician may promptly renew such orders to avoid interruption of the resident's therapeutic regimen. Policy Medication Administration last revised 11/18/17 documents under a section titled Procedure, 3. Medications must be prepared and administered within one hour of the designated time or as ordered. and 21. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available; 22. Notify the physician as soon as practical when a scheduled dose…

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

Based on record review and interview, the facility failed to ensure one resident (R1) of three residents received prescribed medication for anxiety as per a physician order without significant error in a total sample of three resident reviewed for medication errors. Findings include: Policy last reviewed 09/27/17 titled Conformance with Physician Medication Orders Policy documents, (All) medications shall be given as prescribed by the physician and at the designated time. Procedure: 7. The resident's attending physician shall be notified of medications about to be stopped so the physician may promptly renew such orders to avoid interruption of the resident's therapeutic regimen. Policy Medication Administration last revised 11/18/17 documents under a section titled Procedure, 3. Medications must be prepared and administered within one hour of the designated time or as ordered. and 19. Document any medications not administered for any reason by circling initials and reason for omission and initials. and 21. If the medication is not available for a resident, call the pharmacy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately complete MDS (Minimum Data Set) Assessments for one of three residents (R1) reviewed for changes in condition in the sample of five. Findings include: The facility's MDS (Minimum Data Set) Coordinator/Care Plan Coordinator job description (undated) documents, The Care Plan Coordinator is responsible for the timely and accurate completion of the MDS. R1's A.I.M. (Acute Illness Management) for Wellness dated 7-19-23 and signed by V16 (RN/Registered Nurse) documents R1 had a change of plane (fall) while trying to reach for his cell phone and slight discoloration was noted to the right hip. R1's Physician's Order dated 9-10-23 documents, Hydrofera Blue (antibacterial foam dressing) ready foam external pad, apply to lower right ankle wound every Sunday. R1's Wound Care Visit Summary Initial Encounter dated 1-16-24 documents, Wound of right ankle initial encounter. Cleanse with soap and water. Apply lotion to peri-wound. Apply hydro (water-filled)…

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

Based on record review and interview the facility failed to ensure a staff member treated a resident with respect for one of three residents (R1) reviewed for resident rights in the sample of three. Findings include: The facility's Resident Rights policy dated 11/2018 documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. R1's BIMS (Brief Interview of Mental Status) dated 3-25-24 documents R1 is cognitively intact. The facility's typed interview statement dated 5-25-24 and received from V6 (RN/Registered Nurse) documents, I (V6) had told (R1) he could only have one cigarette due to tornado warnings being around us. Then (R1) went to call his mom (V7). I then said to (R1) what are you tattling to your mother about now? On 5-28-24 at 10:40 AM R1 stated, (V6/RN/Registered Nurse) called me a tattletale because I was talking to my mom. (V6) needs to learn some respect and not be so rude. I did not feel abused. I felt disrespected. On 5-28-24 at 10:50 AM V1 (Administrator-In-Training) stated, (V7/R1's Mother)…

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

Based on record review and interview, the facility failed to revise a Comprehensive Care Plan for one resident (R1) of three residents reviewed for Care Plan revision in a sample of three. Findings includes: The facility's Comprehensive Care Plan Policy dated 11/1/17 documents: It is the policy of (Facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1.b. The Care Plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the Resident. The facility's Resident Monitoring Policy, undated, documents: (Facility) may initiate monitoring of residents as nursing measure to assist 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 interview and record review, the facility failed to provide supervision to prevent a fall for one (R1) resident of three residents reviewed for accidents/supervision in a sample of three. Findings include: The facility's Fall Prevention Policy, Revised 11/10/18, documents: Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. All staff must observe residents for safety. The facility's Resident Monitoring Policy, undated, documents: (Facility) may initiate monitoring of residents as nursing measure to assist in providing safety to residents that are identified to be a potential threat to self or others or an elopement risk. 1. Assess resident and document for need for monitoring. R1's AIM (Assess, Intercommunication, Manage) for Wellness Communication Form dated 4/12/24 documents: Resident was sitting in the dining room eating supper just prior to/at the time of the event;…

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 specialized rehabilitation services as ordered for three (R1, R2, R3) of six (R1-R6) reviewed for therapy services in the sample of six. Findings include: The Facility Assessment, dated 2/29/24, documents, Services and Care We Offer Based on our Residents' Needs: Therapy: PT (Physical Therapy)/OT (Occupational Therapy), Speech/Language, Respiratory, Music, Art, management of braces, splints. On 3/4/24 at 8:30 a.m., V1 (Administrator in training) stated, The last day that the previous therapy company was in the building was on 2/16/24. We do not have a start date for the new therapy. V1 also stated there is no therapy in the building for any type of service for any of the residents at this time. 1. R1's Hospital Physician Discharge summary, dated [DATE], documents, Discharge Diagnoses: Principal Problem: Acute Closed fracture of right femoral neck. Disposition: PT/OT ordered-patient has been tolerating OOB (Out of Bed) to chair.…

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 have a complete record for five of six residents (R1, R3-R6) reviewed for specialized therapy in the sample of six. Findings include: The facility's undated Medical Records policy documents, The facility shall have a medical record system that facilitates the retrieval of information regarding individual residents. Each resident shall have an active medical record. This medical record shall be kept current, complete, legible and available at all times to authorized personnel. The medical record will contain up to three months information for each section of the chart. The original physician's orders and department assessments will be retained in the record. The department such as Dietary, Physical Therapy, Occupational Therapy, Speech, Activities and Social Services may keep up to one year of documentation. The information removed from the record will be kept in a folder with other active medical records. A facility document titled Therapy Services, dated 2/29/24, was provided by V1 (Administrator in Training) on 2/29/24…

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

Based on record review and interview the facility failed to ensure that a Registered Nurse was staffed a minimum of eight hours in a 24 hour period for 2 days of 10 reviewed for staffing. This has the potential to affect all 87 residents residing in the facility. Findings include: The facility's Daily Staffing Sheets, dated 9/23/23 and 9/24/23, did not document eight hours of Registered Nurse coverage. On 9/25/23 at 1:00 pm, V1, Administrator, verified that a Registered Nurse was not scheduled on 9/23/23 and 9/24/23. The facility's Resident Census and Conditions of Residents form, dated 9/26/23, documents 87 residents reside in the building.

Based on interview, observation and record review, the facility failed to label and date opened food items in the kitchen and ensure that kitchen equipment was clean and in working order. This has the potential to affect all 87 residents residing in the facility. Findings include: The facility's Storage policy, revised 10/20, documents that all items will be dated upon receipt. Individual cans or bags shall each be dated to ensure that stock is rotated properly. Store leftovers in covered, labeled and dated containers under refrigeration or frozen. When using only part of a product, the remaining product should be in the original package or airtight container and labeled and dated. The facility's Cleaning Schedule, dated 10/14, documents that tasks are divided into categories that must be completed daily, weekly and monthly. Each position in the Dietary Department is assigned certain cleaning tasks to be completed at a particular frequency. The monthly cleaning schedule documents that the AM cook is to clean the top and bottom of the convection oven inside and out on Monday and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to explain the arbitration agreement in a manner that the resident and their representative understands and acknowledge if the resident and their representative understood the agreement. This had the potential to affect all 87 residents residing in the facility. Findings include: The facility's Agreement to Resolve Disputes by Binding Arbitration, no date, documents, The agreement waives resident's right to a trial in court and a trial by jury for future legal claims resident may have against facility. R24's Current Electronic Medical record documents that R24 was admitted to the facility on [DATE]. R24's Agreement to Resolve Disputes by Binding Arbitration, dated 4/4/15, documents that V15 (R24's family) signed the binding arbitration agreement on this date. On 09/28/23 at 10:25 AM, V15 stated, When (R24) was admitted , I was handed a large stack of papers and said to sign them. I don't know what you mean by arbitration. If I had known what that was when…

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

Based on observation, interview, and record review, the facility failed to maintain a clean comfortable homelike environment for two of two residents (R59, R79) reviewed for clean comfortable homelike conditions in the sample of 34. Findings include: The facility's Housekeeping & Laundry Supervisor Job Summary, no date, documents, The Housekeeping and Laundry Supervisor is responsible for planning, organizing, developing and directing the overall operation of the Housekeeping and Laundry Departments in accordance with current federal, state, and local standards, guidelines and regulations governing our facility and as may be directed by the Administrator to assure that our facility is maintained in a clean, safe, and comfortable manner. 1. On 09/25/23 at 12:24 PM, R59 was alert and oriented sitting up in her bed. R59's air conditioning wall unit had a numerous amount of small black fuzzy spots covering the vents of the unit, and cobwebs hanging from the ceiling. R59 stated, The housekeepers come in here and sweep and mop that's it. The spots on the air conditioner are mold which is…

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

Based on record review, interview and observation the facility failed to follow operational policies and procedures, notify the Abuse Coordinator of an injury of unknown origin, and to investigate an injury of unknown origin for one of one resident (R67) reviewed for injury of unknown origin in a sample of 34. Findings Include: The facility policy, named Abuse Prevention Program, revised 11/28/2016, documents, Supervisors shall immediately inform the administrator of all reports of mistreatment, exploitation, neglect and abuse of resident. Upon learning the report, the administrator or designee shall initiate an investigation. Anonymous reports will also be thoroughly investigated. R67's Skin Only Evaluation, dated 9/22/2023, documents Does (R67) have current skin issues: YES. Skin issue number one: scattered bruising to right arm. Skin Note: (R67) woke up this morning with scattered bruises to her right arm and one on her right hand. Cause is unknown. On 9/25/2023 at 10:45AM (R67) was sitting at the dining room table. (R67) is alert with confusion. (R67) had a bruised area to 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, record review and observation, the facility failed to report the allegation of abuse for a bruise of unknown origin to the Abuse Coordinator/Administrator for one of one resident (R67) reviewed for abuse in a sample of 34. Findings Include: The facility policy, named Abuse Prevention Program, revised 11/28/2016, documents, Internal Reporting Requirements and Identification of Allegations: Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents or suspect to supervisor and the administrator. Supervisors shall immediately inform the administrator or his/her designated representative of all reports of potential/alleged mistreatment, exploitation, neglect, and abuse of residents. Nursing supervisor is responsible for reporting to the Administrator or designee. (R67's) Skin Only Evaluation, dated 9/22/2023, documents, Does (R67) have current skin issues: YES. Skin issue number one: scattered bruising to right arm. Skin Note: (R67) woke up this morning with scattered bruises to 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.

Based on record review, interview and observation the facility failed to investigate a bruise of unknown origin for one of one resident (R67) reviewed for injury of unknown origin in a sample of 34. Findings Include: The facility policy, named Abuse Prevention Program, revised 11/28/2016, documents, Supervisors shall immediately inform the administrator of all reports of mistreatment, exploitation, neglect and abuse of resident. Upon learning the report, the administrator or designee shall initiate an investigation. Anonymous reports will also be thoroughly investigation. (R67's) Skin Only Evaluation, dated 9/22/2023, documents, Does (R67) have current skin issues: YES. Skin issue number one: scattered bruising to right arm. Skin Note: (R67) woke up this morning with scattered bruises to her right arm and one on her right hand. Cause is unknown. On 9/25/2023 at 10:45AM (R67) was sitting at the dining room table. (R67) is alert with confusion. (R67) had a bruised area to the right forearm that contained four spaced circular bruises. The bruises were greenish brown in color with…

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

Based on observation, interview, and record review, the facility failed to provide showers to residents requiring assistance for one of one resident (R59) reviewed for ADLs (Activities of Daily Living) in the sample of 34. Findings include: The facility's Bath/Shower policy, dated 3/20/23, documents, Policy: To ensure adequate hygiene needs are met. A bath/shower is scheduled for all residents in the facility at least weekly. R59's Task List Report, dated 9/28/23, at ADL-Bath prefers: Resident's scheduled shower day is every Monday/Thursday to be given on 1st shift. R59's MDS (Minimum Data Set), dated 7/5/23, documents in Section G Activities of Daily Living Assistance that R59 is totally dependent on one person physical assist for bathing. On 09/25/23 at 12:24 PM R59 was alert and oriented sitting up in her bed. R59's hair had a wet appearance to it. R59 stated, I'm pissed off! I don't get out of bed because I'm scared someone will drop me. So, I stay in bed. Because of this I only get bed bathes, and that is totally my choice. However, it's been weeks since I've even had a bed…

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 residents wound was treated timely and a physician ordered treatment order was put in place upon wound identification for one of two residents (R12) reviewed for wounds in the sample of 34. Findings include: The facility's Dressing Change policy dated 3/16/23, documents Policy: To avoid introducing organisms into a wound. Responsibility: All Licensed Personnel. Procedure: Obtain physician's order for dressing change. Cleanse wound per physician's order or use gauze and forceps or cotton applicators. Document procedure in nurse's notes. R12's electronic medical record documents R12 has diagnoses of Peripheral Autonomic Neuropathy and Gout. R12's most recent Minimum Data Set assessment, dated 4/13/23, documents R12 is cognitively intact. On 9/25/23 at 11:10 AM, R12 was sitting in her room in a wheelchair watching television. R12 confirmed she has had her right leg amputated due to her diabetes. R12's lower left shin had an open wound that was red and oozing and approximately quarter sized. The…

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

Based on observation, interview, and record review, the facility failed to check a g-tube (gastrostomy tube) for residual or flush the g-tube with water prior to administering medications and failed to obtain a physician ordered water flush for prior to and after administering medications for one of one resident (R79) reviewed for g-tubes in the sample of 34. Findings include: The facility's Enteral Feeding policy, no date, documents, Physician order for pre-med and formula administration flushes will be sought. The facility's policy for Administration of Medication via a Feeding tube, dated 3/17/23, documents, Put gloves on. Stop the feeding and disconnect tubing if you are interrupting a continuous pump feeding. Check for tube placement by checking for residual. Using a 30 ml (milliliters) or larger syringe, rinse the tube with 30 ml of warm water before administration of prepared medications. Pulverize crushed medications and disperse well in water as indicated above before administration of prepared medication. Flush/rinse tube with 30 ml of water after administration 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 interview and record review, the facility failed to obtain physician ordered laboratory values for one of one resident (R59) reviewed for anticoagulant monitoring in the sample of 34. Findings include: The facility's Laboratory Tests policy, dated 9/27/17, documents, Policy: Appropriate laboratory monitoring of disease processes and medication requires consideration of many factors including concomitant disease(s) and medication(s), wishes of the resident and family and current standards of practice. Procedure: Laboratory testing will be completed in collaboration with Medicare guidelines, pharmacy recommendations and physician orders. Obtain laboratory orders upon admission, readmission, and PRN (as needed) for medication and condition monitoring per the physician's orders. R59's Physician progress note, dated 12/28/22, documents, Assessment & Plan: CBC (Complete Blood Count) every two months and now (long term anticoagulant). R59's Physician's orders, dated 9/27/23, document that R59 has an order to receive Eliquis (anticoagulant) 2.5 mg (milligrams) by mouth two times 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 wear gloves while directly handling medications and while administering gastrostomy tube medications for one of nine residents (R79) reviewed for medication administration in the sample of 34. Findings include: The facility's Administration of Medication via a Feeding tube, dated 3/17/23, documents, Put gloves on. Stop the feeding and disconnect tubing if you are interrupting a continuous pump feeding. Check for tube placement by checking for residual. Using a 30 ml (milliliters) or larger syringe, rinse the tube with 30 ml of warm water before administration of prepared medications. Pulverize crushed medications and disperse well in water as indicated above before administration of prepared medication. Flush/rinse tube with 30 ml of water after administration of prepared medications. Reconnect the tubing and resume the feeding at the prescribed rate if on continuous feeding. Dispose of used equipment/supplies or return to appropriate setting. Remove gloves. Wash hands. On 09/27/23 at 02:02 PM, V6…

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.