Arcadia Care Watseka

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a residents (R1) right to be free from inappropriate touching and sexual comments by another resident (R2), for 1of 5 residents reviewed for abuse. Findings include:The Facility's Abuse Prevention and Reporting Policy dated 9/2024 documents: Guidelines: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident-sensitive and resident-secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent the occurrence of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents. Definitions:…

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 sufficient Registered Nursing (RN) hours on nine of forty-four days reviewed for RN staffing. This failure has the potential to affect all 61 residents in the facility. Findings include:The Facility Nursing Daily Schedule dated July 12,2025 through August 24, 2025, documents on 7/12/25, 7/13/25, 7/22/25, 7/23/25, 7/30/25, 8/6/25, 8/14/25, 8/20/25 and 8/24/25, the facility scheduled zero (0) hours of RN coverage for a 24-hour period. On 8/25/25 at 12:30pm, V2 Director of Nursing (DON) and V5 Regional Director of Operations confirmed the hours listed on the facility nursing daily schedule were correct and the facility failed to have RN coverage on 7/12/25, 7/13/25, 7/22/25, 7/23/25, 7/30/25, 8/6/25, 8/14/25, 8/20/25 and 8/24/25The Facility Resident Midnight Census dated 8/24/25 documents 61 residents reside in the facility.

Based on observation, interview and record review, the facility failed to ensure the director of food services met the regulatory qualifications. The current Dietary manager was not a certified dietary manager, certified food service manager, or credentialed as required. This failure effects all 61 residents.Findings include:On 8/24/25, 8/25/25 and 8/26/25, V6 (Dietary Manager) was actively supervising dietary operations in the facility kitchen during resident meal preparations. V6 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Resident Census and Conditions of Residents report dated 8/24/25 documents 61 residents reside in the facility.Facility Assessment Tool documents: Facility Resources Needed to Provide Competent Support and Care for our resident Population Every Day and During Emergencies. Position Dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. 1 Full Time Food Service Manager.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to coordinate a Pre-admission Screening and Resident Review (PASARR) for residents with mental illness diagnosis during their residency at the facility. This failure affects three (R4, R6, and R37) of five residents reviewed for PASARR II completion in the sample list of 29. 1. R4's Face Sheet dated 8/26/25 documents R4 was originally admitted to the facility on [DATE]. R4's Electronic Medical Record documents R4 had the following medical diagnoses Schizoaffective and Bi-polar (4/19/23). R4's PASARR Level I dated 5/12/22 documents a Level II screening is not indicated because there is no evidence of a serious behavioral health condition/SMI/ID/RC (Serious Mental Illness, Intellectual Disability and/or Related Condition). If changes occur or new information refutes these findings, a new screen must be submitted. 2. R37s Face Sheet dated 8/26/25 documents R6 was originally admitted to the facility on [DATE]. R37's Electronic Medical Record documents R37 had…

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 medications according to physician's orders for one (R6) of three residents reviewed for medication administration in the sample list of 29. This failure resulted in five medication errors out of 25 opportunities, resulting in a 20% medication error rate.On 8/24/25 at 9:33am, V3 Licensed Practical Nurse (LPN) administered the following medications to R6: Fluticasone-Salmeterol (Advair) Inhaler 100-50 micrograms (mcg) 1 puff, Loratadine 10 milligrams (mg), Famotidine 40mg, Folic Acid 800mcg, Furosemide 40mg, Gabapentin 300mg, Losartan Potassium 50mg, Oxybutynin ER 10mg, Psyllium Husk Powder 1 tablespoon in water, Sennosides-Docusate Sodium (Senna) 8.6-50mg, and Oxycodone 5mg.R6's Physician Order Sheet (POS) dated 8/25/25 documents the following orders: Fluticasone-Salmeterol (Advair) Inhaler 100-50 micrograms (mcg) 1 puff inhaled to be given twice a day, Loratadine 10 milligrams (mg) daily, Famotidine 40mg daily, Folic Acid 1mg daily, Duloxetine 60mg daily, Furosemide 40mg twice a day, Gabapentin…

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 reweigh a resident (R3) for a documented significant weight gain, failed to accurately document meal intakes and provide nutritional supplementation as ordered for a nutritionally high-risk resident (R61), and failed to obtain weekly weights as ordered for two (R3 and R61) of four residents reviewed for nutrition in the sample list of 29.1. R61's Face Sheet dated 8/26/25 documents R61 has a diagnosis of Protein-Calorie Malnutrition. R61's Dietary Note dated 7/14/25 documents R61 has significant weight lost noted times six months and continue to monitor weights and intakes. Further documents R61 is on multiple supplements including fortified ice cream daily and nutritional shake three times a day. R61's Care Plan (current) documents R61 is at nutritional risk with interventions including monitoring weights/meal intakes and providing supplements as ordered. Further documents to alert nurse/dietician if not consuming supplements on a routine…

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 upon interview and record review, the facility failed to have a Registered Nurse (RN) providing services at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 62 residents currently residing in facility. Findings Include: The Facility Assessment Tool for Arcadia Care of Watseka dated November 2024 through November 2025 documents staffing should include one registered nurse (RN), two licensed practical nurses (LPN), and six certified nursing assistants (CNA's) for the 6:00 AM thru 6:00 PM shift and one registered nurse (RN), one licensed practical nurse (LPN), and five certified nursing assistants (CNA's) for the 6:00 PM thru 6:00 AM shift. The facility's March 2025 Nursing Schedule documents no Registered Nurses coverage on the following dates 3/8, 3/9, 3/13, 3/14, 3/17, and 3/18/25. The facility's daily assignments document indicates no RN coverage over a 24 hour period for the dates of 3/8, 3/9, 3/13, 3/14, 3/17 and 3/18/25. On 3/24/25 at 1:20 PM, V7 Regional Registered Nurse and V2 Director of Nursing confirmed there are…

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

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 62 residents in the facility. Findings Include: On 3/22/25, 3/23/25 and 3/24/25 V3 Dietary Manager was actively supervising dietary operations in the facility kitchen. On 3/11/25 at 11:04 AM V3 Dietary Manager stated that V3 was hired a couple of weeks ago as Dietary Manager. V3 stated that V3 is not currently a Certified Dietary Manger. V3 stated at this time V3 fails to meet the State of Illinois standards to be a food service manager/dietary manager. On 3/22/25 at 2:02 PM V1 Administrator confirmed that V3 Dietary Manager does not currently have a valid Food Safety/Dietary Manager Certificate as required. The Facility Assessment (not dated) documents a full-time dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services is needed to provide competent support and care for the facility's resident population every day and during…

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 upon observation, interview and record review the facility failed to employ an Infection Prevention Nurse that physically works onsite in the facility at least part time. This failure has the potential to affect all 62 residents residing in the facility. Findings Include: Observations were made on 3/22/25, 3/23/25 and 3/24/25 between the hours of 8:30 AM and 4:00 PM. During these times, no certified Infection Preventionist nurse was in facility. On 3/24/25 at 2:00 PM, V7 Regional Registered Nurse stated the facility's Infection Preventionist is a Regional Infection Preventionist (V25) who works offsite. V7 stated V25 is responsible for all infection tracking and logs and that these are not kept/maintained in the facility. On 3/25/25 at 9:18 AM V2 Director Of Nursing (DON) stated she believes they are supposed to be tracking resident infections but that V25 Regional Infection Preventionist keeps track of resident infections. V2 stated she herself does not have access to the infection tracking log. On 3/25/25 at 9:32 AM V25 Regional Infection Preventionist stated she is at 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 repeatedly failed to provide showers to residents according to their plans of care, physician orders, and preferences. This failure affects three residents (R17, R45, R61) out of five reviewed for activities of daily living on the sample list of 35. Findings Include: Facilities Bathing - Shower and Tub Bath Policy dated October 2024 documents: Purpose: To ensure resident's cleanliness to maintain proper hygiene and dignity. Guidelines: A shower, tub bath or bed/sponge bath will be offered according to resident's preference, no less than once per week or according to the resident's preferred frequency and as needed or requested. 1. On 3/22/25 at 10:20 AM, R45 was seated in a tilt back wheelchair in R45's room. R45 was unshaven and had long nails. R45 Medical diagnoses; Encounter for Palliative Care, Dementia, Anxiety Disorder, Chronic Atrial Fibrillation and Schizoaffective Disorder. R45's Minimum Data Set (MDS) dated [DATE] documents R45's…

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

Based on observation, interview, and record review, the facility failed to provide and implement activities to meet the interest and needs of the residents. This failure affects four residents (R8, R55, R57, R63) of thirteen residents reviewed for activities in the sample list of 35. Findings Include: All four residents (R8, R55, R57, R63) reside on the facility's locked memory care unit/hallway. On 3/22/25 at 9:45 AM, 10:00 AM, 2:00 PM and 3/23/25 at 9:40 AM, and 11:00 AM. all four residents (R8, R55, R57, R63) were in their rooms asleep or sitting not engaged, with no structured activities. 1. R8's undated diagnoses list includes: Unspecified Dementia, unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R8's Care Plan (current), documents R8's preferences for activities are horticulture based activities or crafts, allow resident to choose preferred craft activity; assist with arranging community activities; and ensure the activities the residents is attending is compatible with physical and mental capabilities, compatible…

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

Based on interview and record review, the facility failed to report an allegation of verbal abuse for one (R36) of four resident reviewed for abuse in the sample list of 35. Findings Include: On 3/23/25 at 11:39 AM V2 Director of Nursing (DON) stated R36 told V2 last week that the agency nurse V13 Licensed Practical Nurse (LPN) was very rough in her approach with him, her tone was harsh to him and that the nurse was talking about other residents to R36. V2 stated V2 did not tell V1 Administrator about it but stated she thought R36 told V1 himself. V2 stated she did not recognize R36's allegation as potential abuse at the time. V2 (DON) stated all potential abuse is supposed to be reported immediately to V1 Administrator. On 3/2/25 at 9:10 AM V1 Administrator stated R36 had not reported any abuse to V1 and no staff member reported any abuse regarding R36. V1 was not aware of R36's potential abuse allegation. The facility's Abuse Prevention and Reporting-Illinois Policy dated October 2022 documents employees are required to report any incident, allegation or suspicion of potential…

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 coordinate a Pre-admission Screening and Resident Review (PASARR) level II evaluation for two (R21, R62) of three residents reviewed for PASARR II completion in the sample list of 35. Findings Include: 1. R21's Medical Diagnoses List dated March 2025 documents R21 was admitted to the facility on [DATE] and had a diagnoses of Schizoaffective Disorder: Bipolar Type and Anxiety Disorder. R21's Preadmission Screening and Resident Review (PASARR) Level I screening dated 10/9/23 documents a Level II screening is not indicated because there is no evidence of a serious behavioral health condition (Serious Mental Illness) however, if changes occur or new information refutes those findings a new screen must be submitted. On 3/23/25 at 9:25 AM V5 Business Office Manager confirmed the Preadmission Screening and Resident Review (PASARR) Level I was completed for R21 on 10/9/23 before he was transferred to the facility. V5 confirmed R21's PASARR Level I screening…

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 an appropriate indwelling urinary catheter collection bag and failed to secure the bag in a safe and dignified manner for one of one resident (R63) reviewed for indwelling urinary catheters on the sample list of 35. Findings Include: R63's undated diagnoses list documents R63's diagnoses as: Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Chronic Kidney Disease Stage IV, Calculus of Ureter, and presence of Urogenital Implants. R63's Physician Order Sheet (POS) dated March 2025, documents an order for 16 (french)Fr/10 (cubic centimeters)cc related to other Obstructive and Reflux Uropathy. On 03/22/25 at 9:30 AM, R63's catheter bag was attached to R63's pants visible to all. R63's catheter tubing is looped down through his pant leg, exiting at the bottom then looped back up and secured on the outside of R63's pants. On 3/22/25 at 9:40 AM, V9 Licensed Practical Nurse (LPN) stated there are no leg bags available but confirmed R63 should have a leg bag on for safety and dignity. On 3/22/25…

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 sufficient Registered Nursing (RN) hours on six of fifteen days reviewed for RN staffing. This failure has the potential to affect all 66 residents in the facility. Findings include: The facility Nursing Daily Schedule (February 20, 2025 through March 6, 2025) documents on 2/22/25, 2/23/25, 2/27/25, 3/3/25, 3/4/25, and 3/5/25, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 3/6/25 at 12:25pm, V3 Regional Director confirmed the hours listed on the facility nursing daily schedule were correct and the facility failed to have RN coverage on 2/22/25, 2/23/25, 2/27/25, 3/3/25, 3/4/25, and 3/5/25. The facility Resident Midnight Census dated 3/6/25 documents 66 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents (R1) right to be free from physical abuse by another resident (R2) for one of five residents (R1) reviewed for abuse in the sample list of 10. Findings include: R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses: Sequelae of Cerebrovascular Disease, Hemiplegia and Hemiparesis following Infarction Affecting Right Dominant Side, Schizoaffective Disorder Bipolar type, Anxiety Disorder, Acute Kidney failure, Cerebral Infarction, muscle Weakness and Difficulty in Walking. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 11, moderate cognitive impairment. R1's Abuse and Neglect Screening assessment dated [DATE] documents R1 is a high risk for abuse. R1's Social Service Note dated 1/31/25 at 12:04pm documents Psychosocial assessment reviewed for R1. Assessment completed due to Verbal Altercation - R1 to R2. Behavioral…

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 develop and implement a person-centered comprehensive care plan with intervention for behaviors. This failure affects one resident (R6) of four residents reviewed for behaviors in the sample list of ten. Findings include: R6's Facility Census documents R6 was admitted to the facility on [DATE] and has the following medical diagnoses: Dementia and Schizophrenia. R6's Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status (BIMS) score 10, moderate cognitive impairment. R6's Nursing Note dated 1/4/25 at 3:49am documents R6 was restless during night shift and declined to go to sleep. R6 also refused help with personal cares from Certified Nursing Aides and R6 also refused to wear brief. R6's Nursing Note dated 1/15/25 at 5:57am documents R6 came out of R6's room around 2:00am, with no pants/underwear or (brief) on. R6 did have on a hat, coat, gloves and appropriate footwear. When writer told R6, R6 didn't have any pants, R6…

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 showers for four (R6, R7, R8 and R9) of four dependent residents reviewed for showers and failed to provide dental care for one (R9) of four residents reviewed for dental care from a total sample list of nine residents reviewed for dependent care. Findings include: The facility bathing policy dated October 2024 documents that a shower or bath will be offerred according to resident preference at a minimum of once per week. The facility morning and bedtime care policies dated October 2024 document that dental care will be provided both morning and night to promote comfort, cleanliness, and dignity. 1.) On 12/31/24 at 1:30PM, R6 was laying in bed with yellowed fingernails measuring over an inch past the nail, with particulates of unknown substances under them. R6 appeared disheveled and stale smelling. On 12/31/24 at 1:30PM, R6 stated, I haven't had a shower in a long time, I don't know how long, but its been more than a week. They…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a residents right (R3) to be free from Abuse by another resident (R1), for two (R1, R3) out of three residents reviewed for abuse in the sample list of nine residents. Findings include: The facility policy titled 'Abuse Prevention and Reporting', reviewed 9/2024, documents this facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. The purpose of this policy is to assure that the facility is doing all that is within it's control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. Abuse: Abuse means any physical or mental abuse injury or sexual assault inflicted upon a resident other than by accidental means. R1's Minimum Data Set (MDS)…

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 staff a Registered Nurse (RN) for eight consecutive hours per day. This failure has the potential to affect all 68 residents residing in the facility. Findings include: On 12/3/24 at 11:54 AM V3 RN was working on the memory care unit of the facility. V3 stated this is V3's third day working for the facility. The facility's Daily Assignment Sheets dated 11/21/24-11/24/24, 11/27/24, 11/28/24, 11/30/24, and 12/1/24 do not document the facility had an RN on duty for eight consecutive hours each day. The facility's Daily Assignment Sheets dated 11/20/24, 11/25/24, and 11/26/24 document V2 Director of Nursing worked between three and four hours on second shift on these dates and there were no other RNs listed. On 12/3/24 at 2:20 PM the Daily Assignment Sheets were reviewed with V2. V2 confirmed all of the nurses listed on the assignment sheets for 11/21/24-11/24/24, 11/27/24, 11/28/24, 11/30/24, and 12/1/24 are Licensed Practical Nurses (LPNS) and the facility did not have eight consecutive hours of RN coverage each…

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 insulin and diabetic medications timely and as ordered for four (R1, R2, R4, R7) of four residents reviewed for insulin in the sample list of seven. Findings include: The facility's Medication Administration Policy dated October 2024 documents medication administration is documented on the Medication Administration Record (MAR), medications must be administered according to physician's orders including the right time, and to notify the physician of medication errors. The Resident Council Minutes dated 11/27/24 documents concerns with morning medications taking three hours to get and an insulin problem. 1.) R1's November 2024 MARs document to administer Humulin R (Regular insulin) U-500 (concentrated) units/milliliter give 40 units subcutaneously three times daily at 8:00 AM, 11:00 AM and 4:00 PM. There is no documentation that this medication was administered as ordered on 11/6/24 for all doses, 11/9/24 at 4:00 PM, 11/11/24 at 4:00 PM, 11/14/24 at 11:00 AM and 4:00 PM, and 11/25/24 at 4:00 PM. R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to routinely assess for pain and develop a care plan to address pain for one (R1) of five residents reviewed for accidents in the sample list of seven. Findings include: The facility's Pain Management Program dated October 2024 documents the pain assessment protocol will be initiated when: the pain assessment identifies pain on admission with changes in condition including incidents associated with potential for pain, identified on the Minimum Data Set (MDS), pain medication is given routinely or pain is not controlled, a change in condition occurs that requires pain control, a significant increase in use of PRN (as needed) pain medication, there is a change in pain related to behavior/cognition/mood, and when there is a diagnosis associated with pain/discomfort. This policy documents to use a pain rating scale to determine level of pain, develop and implement a care plan to address pain, assess for pain during routine medication administrations 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 develop and implement interventions to address behavioral disturbances associated with dementia for three (R3, R4, R6) of five residents reviewed for abuse in the sample list of 14. Findings include: 1.) The facility's Final Report to IDPH (Illinois Department of Public Health) documents on 2/28/24 at 3:45 PM R7 walked into R3 and R3 pushed R7 causing R7 to fall. The facility's Final Report to IDPH documents the following: On 10/13/2024 at 1:45 PM V1 Administrator in Training was notified of an altercation between R3 and R4. Staff heard scuffling in R4's room and witnessed R3 had R4 by the arm and would not let go. R3 is very territorial (per usual). This most likely occurred due to a recent room change that caused R3 and R4 to share a bathroom. R4 was moved to a different room. R3's Minimum Data Set (MDS) dated [DATE] documents R3 has severe cognitive impairment, hallucinations, and daily verbal, physical, and other behaviors during the review period.…

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 provide quarterly statements for Resident Trust Funds for five (R1, R2, R3, R5, R6) of five residents reviewed for Trust Funds in the sample list of six. Findings include: The facility's undated Resident Funds Policy and Procedure documents The facility will institute security measures to insure that resident funds managed by the facility are safeguarded from theft or mismanagement and shall include: signed vouchers for all resident transactions, computerized tracking of account activity, monthly oversight by the facility Administrator, and signed quarterly statements. On 9/30/24 V1 Administrator in Training provided the facility's Resident Trust Fund binder which contained monthly logs that document transactions, withdrawals, and balances for residents. The binder included R1's, R2's, R3's, R5's, and R6's Resident Trust Fund Transaction Logs dated July-September 2024. These logs were not signed by the residents and there were no signed quarterly…

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 its Surety Bond provided adequate coverage of Resident Trust Funds. This failure affects five (R1, R2, R3, R5, R6) of five residents reviewed for Resident Trust Funds in the sample list of six. Findings include: The facility's undated Resident Funds Policy and Procedure documents a Surety Bond has been purchased to insure the total amount of the facility's Resident Trust Funds. On 9/30/24 V1 Administrator in Training provided the facility's Resident Trust Fund binder which contained monthly logs that document transactions, withdrawals, and balances for each resident. The binder included R1's, R2's, R3's, R5's, and R6's Resident Trust Fund Transaction Logs dated July-September 2024. The facility's July 2024 Resident Trust Fund bank statement documents an ending balance of $136,483.09 on 7/31/24. The facility's August 2024 Resident Trust Fund bank statement documents an ending balance of $146,255.16 on 8/30/24. The facility's September 2024 Resident Trust Fund bank statement documents a balance of $168,628.65 as 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 report an allegation of sexual abuse for one (R1) of four residents reviewed for abuse in the sample list of six. Findings include: The facility's Abuse Prevention Program dated 11/28/16 documents all allegations involving abuse and exploitation must be reported to officials in accordance with state law, including notifying the Illinois Department of Public Health if there is suspicion of sexual abuse within two hours of forming the suspicion, otherwise report within 24 hours. The facility's Fax (Electronic Facsimile) Worksheet IDPH (Illinois Department of Public Health) Notification Form dated 9/13/24 documents on 9/13/24 at 11:00 PM V1 Administrator In Training was notified of an allegation of misappropriation of R1's property involving V3 Business Office Manager and V4 Activity Aide. The facility's investigative file for this allegation included V1's handwritten notes dated 9/13/24 at 11:00 PM which document the facility received an anonymous call alleging that V3 and V4 allowed R1 to touch their breasts and kiss them 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.

Failures at this level require more than one deficient practice statement. A. Based on record review and interview the facility failed to monitor potential exposure sites for Legionella. This failure has the potential to affect all 44 residents who reside in the facility. B.) Based on observation, interview and record review the facility failed to don PPE (Personal Protective Equipment) prior to entering a contact isolation room for one of one resident (R34) reviewed for transmission based precautions in the sample list of 36. Findings include: a.) The Long-Term Care Facility Application For Medicare and Medicaid dated 8/25/24 documents 44 residents reside in the facility. The facility's policy Legionella Policy and Procedures (not dated) states Legionella Bacteria thrive and multiply in hot or cold water systems and storage tanks and then spread through spray from showers and taps. Should concerns are identified the following measures may be initiated to minimize and control the risks: Have the water system inspected, maintained, and cleaned. (Annually). Ensure water cannot…

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 employ a certified Infection Preventionist. This failure has the potential to affect all 44 residents who reside at the facility. Findings Include: The Long-Term Care Facility Application For Medicare and Medicaid dated 8/25/24 documents 44 residents reside in the facility. The facility's Infection Control Surveillance and Monitoring Policy reviewed 12/7/18 states It is the policy of the facility to do routine surveillance and and monitoring of the facility to determine if compliance with work practices and care of protective clothing and equipment is maintained. Procedure: Monitoring the effectiveness of the facility work practices and protective equipment will be conducted by the Administrator, Infection Control Preventionist (ICP) and the Director of nursing (DON). This includes but is not limited to: a. Surveillance of the facility to ensure that required work practices are observed and that protective equipment and clothing are provided and properly used; b. Investigation of known or suspected parenteral exposure 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, comfortable, and functional environment by failing to maintain the building structure to prevent roof leaks. This failure affects one (R12) of 16 residents reviewed for environment in the sample of 36. This failure has the potential to affect all 44 residents residing in the facility. Findings include: On 8/25/24 at 8:09 AM near the nurse's station, centralized area where all of the resident halls connect, and the beginning of the C Hall the ceiling tiles were sagging and had large brown stains. One tile had been removed and there were cords visible hanging down approximately a couple inches below the ceiling. On 8/25/24 at 8:20 AM R12 was lying in bed. R12's room had a brown stained ceiling tile near R12's doorway. R12 stated R12 admitted to the facility in October 2023 and the brown area on the ceiling tile has gotten larger since R12's admission. R12 stated the facility's roof leaks when it rains which is what causes the brown discoloration. On 8/28/24 at 8:40 AM the ceiling tiles near 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 obtain laboratory tests as ordered and repeatedly failed to document blood glucose results for three of three residents (R4, R25, R46) reviewed for laboratory services in the sample list of 36. Findings include: The facility's Glucose Monitoring policy with a revised date of August 2018 documents, Purpose: To monitor resident's blood glucose to assist in the development of an appropriate medication and treatment regime for resident's with a metabolic disorder caused by an imbalance between insulin supply and demand. Document results of blood glucose and insulin dosage on medication sheet. The facility's undated Laboratory Tests policy documents, Obtain laboratory orders upon admission, readmission and PRN (as needed) for medication and condition monitoring per the physician's order. 1.) R4's Order Summary Report documents a diagnosis of Type 2 Diabetes Mellitus with an admission date of 11/18/22. This Order Summary document an order for an A1C (glycated hemoglobin) every three months. R4's pharmacy consultation report dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure for the dignity of two (R5, R15) of 16 residents reviewed for dignity from a total sample list of 36 residents. Findings include: The facility Abuse Prevention Program Policy dated 11/28/16 documents that the facility prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. Additionally the facility seeks to establish an environment that promotes resident sensitivity, resident security, and prevention of mistreatment, exploitation, neglect, and abuse of resident misappropriation of resident property. 1.) R5's Minimum Data Set, dated [DATE] documents that R5 is cognitively intact. R5's Minimum Data Set, dated [DATE] documents that R5 is dependent for personal hygiene. On 8/25/26 at 12:26PM, R5 said that V12 Certified Nursing Assistant (CNA) wasn't always nice to her and could make her feel bad and hurt her feelings. R5 said that V12 CNA would get…

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 schedule a follow up cardiology appointment for one (R46) of two residents reviewed for dialysis in the sample list of 36. Findings include: R46's Diagnoses List documents R46's diagnoses include Type 2 Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease, Seizures, Stenosis of Carotid Artery, and Nonrheumatic Mitral Valve Prolapse. R46's Census documents R46 expired on [DATE]. R46's Hospital Discharge Instructions dated [DATE] documents R46's discharge problems were Acute Respiratory Failure and Hypertension, R46 has dialysis scheduled three times weekly, and to contact V27's office (Cardiologist) to schedule a follow up appointment. There is no documentation in R46's medical record that the facility contacted V27's office to schedule this appointment. On [DATE] at 11:02 AM V11 Social Services Director stated V11 is responsible for scheduling resident appointments. V11 reviewed the facility's appointment calendar and did not see 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 observation, interview and record review the facility failed to obtain treatment orders and implement pressure relieving interventions for three (R5, R14 and R4) of three residents reviewed for pressure ulcer wounds from a total sample list of 36 residents. Findings include: The facility Preventative Skin Care Policy dated October 2006 documents that it is the policy of the facility to provide preventative skin care through repositioning and careful washing, rinsing, drying and observation of the residents skin condition to keep them clean, comfortable, well groomed and free from pressure ulcers. If reddened areas are noted, it will be reported to the Charge Nurse. Any resident identified as being at high risk for potential skin breakdown shall be turned and reposition a minimum of every two hours. The facility Decubitus Care/Pressure Areas Policy dated January 2018 documents that it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse for one (R2) resident from another resident (R1) with known aggressive behaviors. This failure affects two (R1, R2) out of three residents reviewed for abuse in a sample list of three residents. Findings include: R2's undated Face Sheet documents R2's medical diagnoses as Alzheimer's Disease, Altered Mental Status, Need for Assistance with Personal Care, Muscle Weakness, Glaucoma and Delusional Disorders. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS document R2 as being dependent on staff for all areas of Activities of Daily Living. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as severely cognitively impaired. This same MDS documents R1 had no impairment in functional ability and did not require any mobility device. R2's Careplan intervention dated 10/12/2023 instructs staff to cue, orient and supervise as needed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the residents' right to be free from verbal abuse by a staff member. This failure affected two of four residents (R2, R3) reviewed for abuse in the sample of four. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident, such as telling a resident that he/she will never to be able to see his/her family again. The Abuse Investigation Report dated 5/1/24 documents on 4/30/24 at 9:00 PM V5 Agency Nurse was taking residents outside to smoke. R2 reminded V5 that R3 needed a smoking…

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 employ a Registered Nurse to serve as full time Director of Nurses (DON). This failure has the potential to affect all 47 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (5/2/24- 5/3/24) there was no Director of Nurses present and employed by the facility. On 5/3/24 at 1:40 PM V1 Administrator confirmed the facility does not currently employ a full time Director of Nurses. There has not been a full time DON employed by the facility since March 2024. V1 confirmed the facility census is currently 47 residents. The facility's Facility assessment dated [DATE] documents a full time nursing supervisor (Director of Nurses) is required in order to meet the resident's needs and provide competent support and care for the facility's resident population.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident by failing to follow the Abuse Prevention Program and remove an alleged perpetrator and implement interventions in order to keep others free from abuse. This failure affected three of five residents (R1, R2, R3) reviewed for abuse in the sample of nine. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility affirms the right of it's residents to be free from abuse or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse can include such things as hitting, slapping, pinching, and kicking. The policy documents residents who allegedly mistreat or abuse another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable 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 and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on three of eight days reviewed for RN staffing. This failure has the potential to affect all 48 residents in the facility. Findings include: The facility Nursing Schedule (April 19, 2024 through April 26, 2024) document on 4/19/24, 4/20/24, and 4/21/24, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 4/26/24 at 10:22am, V1 Administrator in Training confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have RN coverage on 4/19/24, 4/20/24, and 4/21/24. The facility Resident Midnight Census dated 4/26/24 documents 48 residents reside in the facility.

Based on interview and record review, the facility failed to provide sufficient Registered Nursing (RN) hours on two of 18 days reviewed for RN staffing. This failure has the potential to affect all 49 residents in the facility. Findings include: The facility Nursing Schedule (April 1, 2024 through April 18, 2024) document on Saturday 4/6/24 and Sunday 47/24, the facility scheduled zero (0) hours of RN coverage for a 24 hour period. On 4/18/24 at 9:55am, V1 Administrator in Training confirmed the hours listed on the facility nursing schedule were correct and the facility failed to have RN coverage on 4/6/24 and 4/7/24. The facility Resident Midnight Census dated 4/18/24 documents 49 residents reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe and homelike environment for nine of nine (R1, R2, R3, R4, R5, R6, R7, R8, and R9) residents reviewed for their environment on the sample list of seven. This failure also has the potential to affect all 49 residents residing in the facility. Findings include: On 4/15/24 at 10:00 AM, the facility's drop ceiling had multiple water stained, missing, and bulging ceiling tiles in the hallways, common areas, and in the residents' bedrooms and bathrooms. The stains on these tiles were dark yellow to brown in color, circular, and ranged from saucer to dinner plate width in size. These observations included: two water stained ceiling tiles outside of room [ROOM NUMBER], three water stained ceiling tiles outside of the double doors entering the D hall, five water stained ceiling tiles in a common area where residents watch television, a missing ceiling tile and three water stained ceiling tiles by the double doors going into 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 protect residents' right to be free from abuse perpetrated by another resident. This failure affects two residents (R1 and R3) out of five reviewed for abuse allegations on the sample list of 24. Findings include: 1. The facility's Initial Report to the Illinois Department of Public Health dated 3/8/24 documents an alleged resident to resident altercation. This same report documents the aggressor (R2) was sent to the emergency room for evaluation. The facility's Final Report to IDPH dated 3/11/24 documents R1 had been wandering in and out of other resident's rooms including R2's room. R2 had grabbed hold of R1's wrist and jerked R1's arm. This report documents a staff member (V3, Activity Assistant) attempted to intervene but R2 also grabbed hold of V3's wrist. Another staff member (V14, Certified Nursing Assistant) intervened and was able to separate the involved residents and staff member. This Final Report documents R2 had been hospitalized at a geriatric psychiatric service clinic for evaluation and treatment. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide therapy services as ordered by the physician for three of three residents (R17, R18, R19) out of seven reviewed for therapy on the sample list of 24. Findings Include: The Facility assessment dated [DATE] documents the facility provides therapy services through a contract agency. On 3/20/24 at 1:32 pm, V1 AIT (Administrator in Training) stated the facility currently does not have a therapy service and hasn't since 2/20/24. V1 stated the prior contracted therapy company walked out and stopped providing [NAME] due to non-payment by the facility's corporate ownership entity. V1 further stated a new company had been scheduled to begin providing services at the facility on 3/4/24 but had not yet come to the facility. V1 concluded by stating there were three residents who did not complete their prescribed course of therapy, R17, R18, and R19. 1. R18's MDS (Minimum Data Set) dated 2/13/24 documents R18 is alert and oriented. On 3/20/24 at 10:39 am,…

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 employ a full time Director of Nursing. This failure has the potential to affect all 48 residents who reside at the facility. Findings Include: On 2/6/24 at 8:45 am, V2 AIT (Administrator in Training) stated the facility does not have a DON (Director of Nursing) or anyone serving as a DON full time explaining that the former DON quit on 1/19/24. The Facility assessment dated [DATE] documents the facility will have an RN with administrative duties 8-12 hours a day. The facility Nurses Midnight Census dated 2/5/24 documents 48 residents reside at the facility.

Based on observation, interview and record review the facility failed to ensure a Director of Nursing was working full time in the facility and failed to have a Registered Nurse working eight consecutive hours in a 24 hour period for five of 11 days reviewed. This has the potential to affect all 48 residents residing in the facility. Findings include: The Facility Assessment with a review date of 8/14/23 documents the Administrator as V1 Administrator in Training and does not document any Director of Nursing. The Assessment documents the Facility Staff Needs (hours per day) of Licensed nurses providing direct care as 24 hours per day and Other nursing personnel (e.g. {example} those with administrative duties) as 8-12 hours per day. This Assessment does not distinguish how many of those hours should be from a Registered Nurse or the Director of Nursing. On 1/23/24 at 9:39 AM, V1 Administrator in Training stated that they do not currently have a Director of Nursing. On 1/23/24 at 1:35 PM, V2 former Director of Nursing stated that her last day working for the facility was on 1/12/24.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have a licensed administrator managing the facility. This failure has the potential to affect all 48 residents residing in the facility. Findings include: On 1/24/24 at 10:53 AM, V1 stated that V1 is the facility's Administrator In Training and has been since 8/16/23. V1 stated V1 has not yet applied for a temporary administrator license but is taking classes to do so. V1 stated that V15 Regional Administrator currently holds the administrator license for the facility but is not in the building. The facility's Facility assessment dated [DATE] documents staffing is scheduled based on the facility's needs and required staffing guidelines and does not include an Administrator in those calculations. This assessment lists V1 as the facility's Administrator. The facility's Midnight Census dated 1/23/24 documents 48 residents reside in the building.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to immediately report an allegation of abuse (R1) to the Abuse Coordinator. This failure affects 11 residents (R1, R2, R5, R6, R7, R8, R9, R10, R11, R12, R13) residing on the Dementia unit reviewed for abuse in the sample list of 13. Findings include: The facility's Abuse Prevention Program policy with a revised date of 11/28/2016 documents, The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. 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 and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. The facility's Final Report for the incident dated 1/9/24 at 8:30 PM documents, Summary: (V1/Administrator in Training) was notified of alleged…

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

Based on interview and record review the facility failed to maintain a complete and accurate medical record for one of five residents (R1) reviewed for accuracy of medical records on the sample list of four. Findings include: On 1/23/24 at 9:00 AM, V1 Administrator in Training provided the Abuse Investigations for the prior three months. R1 is documented as having a resident to employee incident on 1/9/24. The facility's Final Report for the incident dated 1/9/24 at 8:30 PM documents, Summary: (V1/Administrator in Training) was notified of alleged verbal abuse from staff-(V4 Certified Nursing Assistant) towards (R1). Investigation: (V1) reviews the facility cameras, and interviewed staff and residents. Based on staff interviews, (V4) was heard yelling and using inappropriate language at (R1) to keep her clothes on. The review of cameras are inconclusive, show (V4) walk off the unit and leaving it unattended. Conclusion: Abuse is unfound, due to lack of evidence. However the employee will be terminated due to not a good fit for our resident or facility. (V1) in-serviced all staff 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 operationalize their Abuse Prevention Program by failing to complete pre-employment background screenings for an employee and failing to investigate and report allegations of misappropriation of property. This failure has the potential to affect four of four residents (R1, R2, R3 and R4) reviewed for abuse on the sample list of four. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents the facility will implement systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively, and make necessary changes to prevent future occurrences. Prior to a new employee starting a work schedule this facility will initiate a reference check from previous employer(s), check the Illinois Health Care Worker Registry on all individuals being hired for a position and potentially bordering states that the individual is known to have been licensed/certified in, based on the individuals resume or other…

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

Based on interview and record review, the facility failed to ensure residents are free of misappropriation of property for one of four residents (R1) reviewed for abuse on the sample list of four. Findings Include: The facility Abuse Prevention Program dated 11/28/16 documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation as defined below. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. R1's MDS (Minimum Data Set) dated 8/30/23 documents R1 is alert and oriented. R1's abuse folder contained a Facility Reported Incidents Smart Sheet Form dated 12/7/23 documents, R1 reported that R1's debit card was missing. R1 called the banking company and was told that R1's card had been used several times. The facility assisted R1 with calling the local police department to file a report on 11/8/23. A print out of transactions dated 11/8/23 documents a total 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 report allegations of misappropriation of resident property to the State Survey Agency and local police for one of four residents (R1) reviewed for abuse on the sample list of four. Findings Include: The facility's Grievance Log contained the following grievance's from R1: 8/29/23 - R1 reported someone tried to use R1's card to pay a bill at Verizon. R1 asked to get more information. R1 called card company and they will refund the money to the card in 7-14 days. Police called and R1 was educated on not giving R1's card to anyone to use and R1 said R1 would work on it. 10/6/23 - R1 claims $105 is missing from R1's room and that the money was in a black sock. This grievance has a response from V9 SSD (Social Service Director) that documents V9 talked with R1 about money and asked R1 questions like where the money came from, is there a receipt to show that much was taken out of the bank or credit card and to verify how R1 knew it was $105. R1 claims R1 received the money from a friend and that person said it was $105. V9 then…

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 allegations of misappropriation of resident property for one of four residents (R1) reviewed for abuse on the sample list of four. Findings Include: The facility's Grievance Log contained the following grievance's from R1: 8/29/23 - R1 reported someone tried to use R1's card to pay a bill at Verizon. R1 asked to get more information. R1 called card company and they will refund the money to the card in 7-14 days. Police called and R1 was educated on not giving R1's card to anyone to use and R1 said R1 would work on it. 10/6/23 - R1 claims $105 is missing from R1's room and that the money was in a black sock. This grievance has a response from V9 SSD (Social Service Director) that documents V9 talked with R1 about money and asked R1 questions like where the money came from, is there a receipt to show that much was taken out of the bank or credit card and to verify how R1 knew it was $105. R1 claims R1 received the money from a friend and that person said it was $105. V9 then asked R1 if R1 had any witnesses 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 the Infection Preventionist had completed required training on infection prevention and control. This failure has the potential to affect all 44 residents residing in the facility. Findings include: The facility's Infection Control Surveillance and Monitoring policy dated as revised 4/11/22 documents the facility will have routine surveillance and monitoring to determine compliance with infection control practices and the Director of Nursing (DON) may perform these duties if the DON has an approved Infection Control Certification. On 10/4/23 at 7:53 AM V1 Administrator in Training (AIT) stated the facility has a few Scabies cases, one confirmed, and two suspected. V1 stated V2 is the DON and is also the facility's Infection Preventionist. On 10/4/23 at 1:27 PM V2 DON stated V2 does not have Infection Preventionist training, and V2 wasn't aware until today that V2 was also responsible for the Infection Preventionist duties. V2 stated V2's employment began on 9/27/23. The facility's Nurses Midnight Census dated 10/3/23…

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 updated infection control logs, report a communicable disease to the local health department, label isolation linen containers, handle linens appropriately, and implement isolation for a resident (R2) with suspected Scabies (a highly contagious skin condition caused by a mite). These failures affect four (R1, R2, R3, R4) of four residents reviewed for infection control in the sample list of four. Findings include: 1.) The facility's Infection Control Logs dated 3/23/23-10/3/23 do not document R1 was diagnosed with Scabies on 10/2/23 or that R2 and R3 were treated for Scabies. R1's Dermatology Progress Note dated 10/2/23 documents R1 had a rash with pustules noted throughout entire body, and R1 tested positive for Scabies on 10/2/23. This note documents orders to administer Elimite 5% cream apply from neck to toes and administer Ivermectin 3 milligrams five tablets once on 10/2/23 and then repeat in 7 days. R2's Nursing Note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide showers as scheduled for one (R3) of three residents reviewed for showers in the sample list of four. Findings include: R3's Minimum Data Set, dated [DATE] documents R3 has severe cognitive impairment and bathing did not occur during the 7 day lookback period. R3's shower documentation for September-October 2023 provided by V1 Administrator in Training and V2 Director of Nursing, documents NA Not Applicable for R3's showers that were scheduled on 9/9/23, 9/15/23, and 9/19/23 and R3 is scheduled to receive showers twice weekly. There was no documentation that R3 received showers scheduled on 9/9/23, 9/15/23, and 9/19/23. On 10/4/23 at 1:27 PM V2 stated R3 is scheduled for showers twice weekly. V2 confirmed staff should document the shower as given or refused, and not NA. At 4:40 PM V2 stated V2 had no additional shower documentation to provide for R3. .

Based on observation, interview, and record review the facility failed to monitor a rash, document weekly skin assessments, and report a newly identified rash to the physician to obtain treatment orders. These failures affect two (R1, R3) of four residents reviewed for rashes in the sample list of four. Findings include: 1.) R1's Physician Progress Note dated 8/17/23 documents R1 has a dermatological rash that is resolving. R1's Shower Sheet dated 8/15/23 and 9/13/23 documents redness to R1's groin. R1's September 2023 Medication/Treatment Administration Record (MAR/TAR) documents to apply Hydrocortisone 0.5 % cream to the right ankle daily as of 4/4/23, apply Clotrimazole External Ointment 1 % topically to perineum twice daily as of 7/31/23, and apply Triamcinolone Acetonide 0.1 % Cream topically to trunk, abdomen, back twice daily for allergic dermatitis. These treatments are documented as administered between 9/1/23 and 9/30/23. This MAR/TAR documents to complete a skin assessment weekly and indicate C=Clear; R=Rash, O=Other, P=Pressure, S= Skin Tear. R1's skin assessments are…

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.