Axiom Healthcare Of West Frankfort

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 5 of 5 residents (R15, R22, R23, R32 and R38) reviewed for call light response times in a sample of 46.Findings include:1. R23's admission record documents an admission date of 10/20/2023 with diagnoses of chronic pulmonary edema, mild intellectual disability, morbid obesity and need for assistance with personal care. R23's MDS (minimum data set) dated 1/15/26 documented R23 with a BIMS (brief interview for mental status) score of 15 out of 15 total, which indicates R23 is without cognitive impairment. This same MDS documented R23 has impairment to both lower legs, uses a wheelchair and is dependent on staff for transfers and toileting care.On 4/12/2026 at 9:10am, R23 said he had to wait 3 hours the previous night (4/11/2026) for his call light to be answered by staff because there are only two staff working on the night shift. R23 said this is how it is every…

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

Based on interview, observation, and record review the facility failed to provide a method to call for assistance from the toilets and shower rooms for 36 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R17, R19, R21, R22, R24, R25, R26, R28, R29, R30, R31, R32, R33, R36, R38, R39, R40, R41, R42, R43, R45, and R46) of 36 residents reviewed for accommodations of needs in a sample of 46.Findings include: On 04/12/26 at 9:15 AM the shower room on the north hall had no call light in the shower stall. On 04/12/26 at 9:16 AM on the north hall, the first bathroom on the left side of the hall had no call light accessible from the floor, the first bathroom on the right side of the hall had no call light accessible from the floor, and the second bathroom on the right side of the hall had no call light accessible from the floor. On 04/12/26 at 9:24 AM on the south hall, the first bathroom had no call light accessible from the floor near the toilet. The second bathroom had no call light accessible from the floor near the toilet. On 04/16/26 at 3:46 PM V1 (Administrator) stated,…

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 maintain repairs to windows, floors, and radiators and keep resident floors, bathrooms, and shower areas clean for 36 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R15, R17, R19, R21, R22, R24, R25, R26, R28, R29, R30, R31, R32, R33, R36, R38, R39, R40, R41, R42, R43, R45, and R46) of 36 resident reviewed for safe clean, comfortable environment in a sample of 46.Findings include: 1. On 04/12/26 8:41AM, R5 who was alert and oriented, stated that he has the insides of his incontinent brief from last night all over his floor. R5 said that his incontinent brief exploded last night, and no one would clean it up for him. On 04/12/26 at 8:42AM, there was a white polymer substance all of the floor next to R5's bed. 2. On 04/13/26 at 11:50AM, R28's room had two ceiling tiles that were pushed up into the ceiling and had what appeared to be some kind of insulation hanging around the ceiling tile track that was pushed up. The area where the ceiling tiles were pushed up is located above R28's nightstand and head…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide supplements as ordered to underweight residents for 4 (R1, R2, R3, and R15) of 6 residents reviewed for nutritional status in a sample of 46.Findings include:1.R15's admission Record documents an admission date of 12/12/25 with diagnoses including: pan lobular emphysema, chronic obstructive pulmonary disease, conversion disorder with seizures or convulsions, chronic kidney disease, anemia, dementia, gastro-esophageal reflux disease, depression, and anorexia. R15's Care Plan documents a focus area of R15 has a potential nutritional problem dated 03/01/26 with interventions including: provide and serve supplements as ordered dated 03/01/26 and RD (Registered Dietitian) to evaluate and make diet change recommendations dated 12/15/25.R15's Order Summary Sheet documents a dietary order of regular diet, regular texture with super cereal at breakfast, whole milk in place of menu milk and fortified pudding at lunch and supper 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.

Based on interview, observation, and record review the facility failed to follow the menu provided for the residents receiving the mechanical soft diet for 6 (R9, R13, R16, R28, R31, and R37) of 6 residents reviewed portion sizes in a sample of 46.Findings include:The document titled, Diet type report documents R9, R13, R16, R28, R31, and R37 receive the mechanical soft diet.On 04/12/26 during lunch service starting at 11:50 AM R9, R13, R16, R28, R31, and R37 received 2 ounces of the ground marinated pork loin with gravy and 4 ounces of soft chopped broccoli with pieces of the broccoli being over one inch in size.The Diet Spreadsheet dated week 3, day 13 documents: mechanical soft ground meat diet: ground marinated pork loin with gravy #8 scoop (0.5 cup/3.75 fluid ounces) and soft chopped broccoli 4 ounce spoodle.On 04/12/26 during lunch service V17 (Dietary staff) served the blue scoop (2 ounces) of the ground pork with gravy to R9, R13, R16, R28, R31, and R37 on the mechanical soft diet. On 04/12/26 at 12:37 PM, V8 (Dietary Manager) stated the blue scoop, the one used to serve 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, observation and record review the facility failed to provide the mechanical soft diet as directed by the recipe for 6 (R9, R13, R16, R28, R31, and R37) of 6 resident reviewed for mechanical soft diets in a sample of 46.Findings include:The document titled, Diet type report documents R9, R13, R16, R28, R31, and R37 receive the mechanical soft diet.On 04/12/26 during lunch service starting at 11:50 AM V17 (Dietary staff) served 4 ounces of broccoli with pieces over one inch in size to R9, R13, R16, R28, R31, and R37 on the mechanical soft diet.On 04/12/26 during lunch service starting at 11:50 AM R9, R13, R16, R28, R31, and R37 received 4 ounces of soft chopped broccoli with pieces of the broccoli being over one inch in size.The Diet Spreadsheet dated week 3, day 13 documents: soft chopped broccoli 4 ounce spoodle.The recipe titled, soft chopped broccoli documents: 4. chop broccoli into bite-sized pieces (1/2 or less). Transfer to steam table pans. Cover and hold until ready to serve. On 04/16/26 at 2:16 PM, V9 (Registered Dietician) stated she would expect 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, observations, and record review the facility failed to follow and maintain proper infection control practice for indwelling catheters and while providing indwelling catheter care and proper sanitation for glucometers for 6 (R2, R5, R19, R29, R31, and R34) of 12 residents reviewed for infection control in a sample of 46. The findings include: 1. R2's admission Record documents an admission date of 11/06/25 with diagnoses in part of obstructive and reflux uropathy. R2's MDS (Minimum Data Set) documents in Section C a BIMS (Brief Interview for Mental Status) score of 13 which indicates R2 is cognitively intact. Section GG document toileting as dependent and transfers as partial/moderate assistance. Section H documents indwelling catheter as yes. R2's Care Plan documents a focus area of enhanced barrier precautions r/t (related to) indwelling urinary catheter with a revision date of 04/01/26. Another focus area of I have indwelling catheter with a revision date of 11/24/25 documents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to respond to a grievance in a timely manner for one (R3) of one resident reviewed for grievance responses in a sample of 46.Findings include: R3's admission record documents diagnoses including: severe protein-calorie malnutrition, muscle wasting and atrophy, anxiety disorder, post-traumatic stress disorder, major depressive disorder, polyarthritis, dementia, acute duodenal ulcer with perforation, anemia, amnestic disorder, vitamin D deficiency, and frontotemporal neurocognitive disorder. R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental status (BIMS) score of 15 indicating R3 is cognitively intact. On 04/15/26 at 9:53 AM, R3 stated the facility has not responded to her grievance that she turned in and she would like to know what they are doing. R3 stated, she filed the original grievance she thinks about three weeks ago and has told them about other concerns she has had with another resident on the weekends every Monday…

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 level II Preadmission screening and Resident review (PASRR) was completed for a resident with a diagnosed mental disorder for 1 (R4) of 2 residents reviewed for PASRR screening in a sample of 46.The findings include: R4's admission record documents an admission date of 04/30/24 with diagnoses in part of major depressive disorder recurrent, unspecified psychosis, anxiety, and insomnia.R4's MDS (Minimum Data Set) dated 02/06/26 documents in Section C a BIMS (Brief Interview for Mental Status) score of 07 which indicates severely impaired cognition.A documents titled Illinois PASRR summary of findings Preadmission Screening and Resident Review report date 05/03/24 with R4's name documents under, why this preadmission screening and resident review occurred: We gathered the information in this report through: No clinical documentation submitted by facility. Interview with you. Interview with nurse. We learned that: Your health is declining. You feel week. You need support to manage your care. A review needed to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to follow the dietary preferences for 2 (R10 and R40) of 12 residents reviewed for dietary preferences in a sample of 46.Findings include:1.R10's admission Record documents an admission date of 07/28/25. R10's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 13 indicating R10 is cognitively intact. R10's Dietary Initial/Quarterly/Annual assessment dated [DATE] documents: food preference 3. dislikes: fish, Brussel sprouts, broccoli, coleslaw, cottage cheese, crabmeat, oranges, pineapple, cucumber.The Diet Spreadsheet dated week 3 day 13 documents for lunch: Italian marinated pork loin, stuffing, roasted broccoli, apple pie, and beverage.On 04/12/26 at 12:06 PM, R10 was served Italian marinated pork loin, stuffing, roasted broccoli, apple pie, and a beverage.On 04/12/26 at 12:40 PM, R10 did not eat any of his broccoli on his plate. When asked, R10 stated, he does not like broccoli.On 04/15/26 at 12:25…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide influenza and pneumococcal vaccinations after consent forms had been signed for 2 (R2 and R15) 5 residents reviewed for immunization in a sample of 46.Findings include:1.R15's admission Record documents a date of birth indicating R15 is [AGE] years of age and diagnoses including: pan lobular emphysema, chronic obstructive pulmonary disease, conversion disorder with seizures or convulsions, chronic kidney disease, anemia, dementia, gastro-esophageal reflux disease, depression, and anorexia. R15's undated consent documents: the question: has the resident received the PCV 13 (pneumococcal conjugate vaccine 13) vaccine in the past with unknown checked and the statement I consent to receive the PCV13 if not previously given or if unknown checked. 2. R2's admission Record documents an admission date of 11/06/25, a date of birth indicating R2 is [AGE] years of age, and diagnoses including: Parkinson's disease, severe protein-calorie malnutrition,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect when providing care to maintain or enhance his or her self-worth and value resident input for 13 (R1, R3, R4, R5, R6, R7, R8, R9, R11, R12, R13, R14, and R15) of 15 residents reviewed for resident rights.Findings include:1. R1's admission Record documented an admission date of 03/31/25 and included diagnoses of muscle wasting and atrophy, lymphedema, venous insufficiency, spondylosis without myelopathy or radiculopathy, rapidly progressive nephritic syndrome, acute duodenal ulcer without hemorrhage or perforation, and spinal stenosis. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1's cognition is intact.On 01/05/26 at 1:20 PM, R1 stated the staff here, especially the Certified Nurse Aides (CNA's) have nasty attitudes, especially at night. R1 stated there is CNA's at night that would give him a lot of attitude…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide food in a manner that was palatable for 14 (R1, R2, R3, R4, R5, R6, R7, R8, R9, R11, R12, R13, R14, R15) of 15 residents reviewed for palatable food.Findings include:1. R1's admission Record documented an admission date of 03/31/25 with diagnoses that included muscle wasting and atrophy, iron deficiency anemia, vitamin deficiency, vitamin B12 deficiency anemia. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status) score of 15, indicating cognition is intact.On 01/07/26 at 10:45 AM, R1 stated they have talked about the facility food and the issues with it in the Resident Council meeting he attended. R1 said they were supposed to have a food council, but he does not know what happened to that. R1 stated he has told the facility staff about the food issues, like the quality of the food, the temperature of the food, and there not being enough meat in the food several times.On 01/05/26 at 1:20 PM, R1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure privacy was maintained for residents. This deficient practice has the potential to affect all 52 resident that reside in the facility. The findings include: 1. On 08/28/25 at 1:30 PM, R13 stated he has heard staff talking about other residents' health issues and conditions where other residents could overhear. R13's Minimum data set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 15, indicating R13 is cognitively intact. 2. On 09/08/25 at 2:55 PM, R33 stated he has heard staff talk about other residents and their health issues and backgrounds. R33's Minimum data set (MDS) dated [DATE] documents a brief interview of mental status (BIMS) of 10, indicating moderately cognitively impaired. 3. On 08/28/25 at 11:35AM, R3 who was alert and orientated stated that a lot of the staff talk about other resident's care and stuff in the dining room and in common areas in front of families and other residents that the care isn't…

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 address a concern area discussed and documented in resident council. This failure has the potential to affect all 52 residents residing at the facility. Findings include:Resident council minutes dated 08/07/25 documents under the section titled, Nursing: some CNAs have hateful attitudes. On 09/05/25 at 3:10 PM (during resident council) R27, stated, the previous concern of CNAs having hateful attitudes has not been resolved. Resident council stated, they have not been given any resolution for that concern. The CNAs act like they do not want to come help you. The staff are always on their phones and some staff still have hateful attitudes. On 09/03/25 at 11:10 AM, V3 (Assistant Director of Nursing) stated the concern of CNAs having hateful attitudes should have been brought up at the morning meeting but she does not remember discussing it. V3 stated, there probably should have been a concern or grievance form documenting a resolution. V3 stated, there 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all staff maintained the appropriate licenses while working at the facility. This failure has the potential to affect all 52 residents residing at the facility. Findings include:On [DATE] at 1:11 PM, V2 (Director of Nursing/ DON) stated V4's (Licensed Practical Nurse/ LPN) license must have expired on [DATE]. V2 stated, V4 worked without a license from [DATE] to [DATE]. V2 stated they did not notice her license expired until [DATE], after that V4 worked as a certified nurse aide.On [DATE] at 11:35 AM, 1.R3 who was alert to person, place and time stated V4 was working as a nurse and now she is working as a CNA (Certified Nursing Assistant) because she didn't renew her nursing license.On [DATE] at 11:43 AM, V9 (CNA), stated V4 was working as a nurse she thought up until June and now she works as a CNA.On [DATE] at 12:23 PM, V11 (LPN) stated, she has worked with V4 as a nurse she said V4 was working as a nurse up till a couple of months ago V11…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide beverages to residents. This failure has the potential to affect all 52 residents residing at the facility. Findings include:1. R1's Transfer/Discharge report dated 08/28/25 documents in part an admission date of 04/12/23 with diagnoses in part of acute kidney failure, urinary tract infection and need for assistance with personal care. R1's MDS (Minimum Data Set) dated 06/30/25 documents a BIMS (Brief Interview for Mental Status) score of 03 which indicates severely impaired cognition. R1's Care Plan documents a focus of risk for dehydration with a date initiated of 04/08/24. On 08/28/25 at 12:47PM, V31 (Family Member) stated he must ask the facility to pass out water more often for R1, because they don't pass out ice and water all that often. V31 said that R1 had a history of urinary tract infections and when he visits R1 she doesn't have any water available in her room. 2. R2's admission record dated 09/10/25 documents an…

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

Based on interview and record review the facility failed to respect the resident rights to have an environment that promotes maintenance and enhancement of his or her quality of life for 40 of 40 residents (R1, R2, R3, R4, R5, R6, R7, R8, R10, R11, R12, R13, R15, R16, R17, R18, R19, R21, R23, R24, R25, R26, R27, R29, R30, R31, R32, R33, R35, R38, R39, R40, R41, R42, R43, R44, R45, R46, R47, R48) that live on the north and south halls reviewed for resident rights in a sample of 48. The findings include: R3's Transfer/Discharge report dated 08/28/25 documents an admission date of 06/12/24 with diagnoses in part of bipolar disorder, delusional disorder, major depressive disorder, schizophrenia, borderline personality disorder, anxiety, and need for assistance with personal care. R3's MDS (Minimum Data Set) dated 06/30/25 documents in Section C a BIMS (Brief Interview Mental Status) score of 15 which indicates cognitively intact. R3's Care Plan documents a focus area of I have increased agitation; restlessness with a date initiated 06/10/25 with an intervention in part of offer 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a method for altering staff when resident's need assistance for 5 (R4, R7, R15, R17, R30) of 15 residents reviewed for call lights in reach in a sample of 48. Findings include: 1. R15's transfer/discharge report documents an admission date with diagnoses including: chronic respiratory failure, chronic obstructive pulmonary disease, anxiety disorder, depression, shortness of breath, cachexia, chronic viral hepatitis C, peripheral vascular disease, and muscle wasting and atrophy. R15's Minimum data set (MDS) dated [DATE] documents a brief interview of mental status of 12 indicating R15 is moderately impaired. Section GG documents sit to stand, chair/bed to chair transfer and toilet transfer as partial/moderate assistance with walk ten feet documented as not attempted due to medical condition or safety concerns. On 08/28/25 at 1:35 PM, R15's oxygen tubing was not in place, it was around her face but it was approximately an inch away…

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 a smoke/vape free building for 5 of 5 residents (R2, R5, R6, R18, R23) reviewed for environment in a sample of 48. Findings Include:On 08/28/25 at 10:06AM, R2 who was alert and orientated stated that she has observed a staff member who was vaping in the hallway of the building. R2 stated that she doesn't know the staff name, but she is the one who looks like a boy. On 08/28/25 at 10:08AM, R6 who was alert and orientated stated that he has witnessed staff vaping in the hallway. R6 said that they vape in the hallway on day and evening shift. R6 said that it has been several staff and didn't want to name any names. On 08/28/25 at 11:23AM, R5 who was alert and orientated stated that she has witnessed staff vaping in the hallways and in some resident rooms. R5 said that they pull out their vapes often. On 09/03/25 9:38AM, R18 who was alert and orientated stated that she has witnessed staff in the building vaping in the hallway. On 09/03/25 at 9:42AM, R23 who was alert and orientated stated that she has witnessed staff…

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 the menu provided to the facility and correct portion sizes directed by the menu for 7 (R2, R3, R6, R9, R11, R13 and R27) of 15 residents reviewed for following the menu in a sample of 48. Findings include:1. R2's admission record dated 09/10/25 documents an admission date of 09/01/20 with diagnoses in part of need for assistance with personal care and unspecified protein-calorie malnutrition. R2's MDS (Minimum Data Set) dated 08/13/25 documents in Section C a BIMS score of 15 indicating R2 is cognitively intact. Section GG eating as supervision or touching assistance. R2's Care Plan documents a focus area of Resident hoards food with a date initiated of 04/03/24. Another focus area of Risk for Malnutrition with a date initiated of 04/03/24 with an intervention in part of provide supervision during meals. On 08/28/25 at 10:06AM, R2 stated that the facility does run out of food often. R2 said they won't have enough food for everyone and then 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, observation, and record review the facility failed to provide enough evening snacks so every resident may have a snack in the evening for 8 residents of 17 residents (R2, R3, R7, R11, R20, R27, R29, and R35) reviewed for evening snacks in a sample of 48. Findings include:R2's admission record dated 09/10/25 documents an admission date of 09/01/20 with diagnoses in part of need for assistance with personal care and unspecified protein-calorie malnutrition. R2's MDS (Minimum Data Set) dated 08/13/25 documents in Section C a BIMS score of 15 indicating R2 is cognitively intact. Section GG eating as supervision or touching assistance. R2's Care Plan documents a focus area of Resident hoards food with a date initiated of 04/03/24. Another focus area of Risk for Malnutrition with a date initiated of 04/03/24 with an intervention in part of provide supervision during meals. On 09/03/25 at 1:45PM, R2 stated that the facility had crappy snacks in the evening or they don't have enough snacks for all 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 ensure residents were free from mental abuse for 1 of 15 residents (R34) reviewed for abuse in a sample of 48. Findings include:R34's admission record documents an admission date of 08/27/25 with diagnoses including: chronic obstructive pulmonary disease with acute exacerbation, acute embolism and thrombosis of femoral vein, enlarged lymph nodes, diverticulitis, nicotine dependence, erythema intertrigo, depression, and anxiety disorder. R34's care plan documents a focus area of: I am at risk for abuse/neglect. Date initiated 8/27/25. Goal, I will be cared for in a safe manner and verbalize to staff any incidences of abuse. Date initiated 9/2/25. Interventions include, Assess resident for risk for risk of abuse, educate resident to speak to staff if feeling uncomfortable with a situation, ensure safety if feeling unsafe, observe resident in care situations, observe resident in company of peers, report any verbalization of abuse or neglect to administrator immediately. All initiated 8/27/25. A report sent to IDPH regarding an…

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

Based on interview and record review the facility failed to report and allegation of staff to resident abuse to the state agency (Illinois Department of Public Health) and failed to report an allegation of staff to resident abuse to the Administrator for 1 of 15 residents (R4) reviewed for abuse and neglect in the sample of 48. The Findings include:1. R4's admission record dated 09/12/25 documents an admission date of 12/07/22 with diagnoses in part of major depressive disorder, overactive bladder, panic disorder, pelvic and perineal pain, personal history of malignant neoplasm of cervix, weakness, and need for assistance with personal care. R4's MDS (Minimum Data Set) dated 06/18/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 06 which indicates R4 has severely impaired cognition. Section GG documents toileting as dependent. R4's Care Plan a focus area with a date initiated of 03/06/25 of Behavior Management with an intervention in part of toilet resident routinely and upon request. If resident requests are continuous remind her of the last time she…

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 and timely investigate an allegation of staff to resident abuse for 1 of 15 residents (R4) reviewed for abuse in a sample of 32 Findings include:1. R4's admission record dated 09/12/25 documents an admission date of 12/07/22 with diagnoses in part of major depressive disorder, overactive bladder, panic disorder, pelvic and perineal pain, personal history of malignant neoplasm of cervix, weakness, and need for assistance with personal care. R4's MDS (Minimum Data Set) dated 06/18/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 06 which indicates severely impaired cognition. Section GG documents toileting as dependent. R4's Care Plan a focus area with a date initiated of 03/06/25 of Behavior Management with an intervention in part of toilet resident routinely and upon request. If resident requests are continuous remind her of the last time she was toileted. Another focus area with a date initiated of 04/04/24 document, at risk for Abuse with intervention in part of investigate…

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 they had RN (Registered Nurse) coverage 8 hours/day, 7 days/week. This failure has the potential to affect all 50 residents who reside at the facility. Findings Include:The undated facility Room Roster documents 50 residents currently reside at the facility. On 8/18/25 at 3:20 PM, V2 (Director of Nurses) stated she didn't have a Registered Nurse on staff. V2 stated she does have agency Registered Nurses that work at the facility at times. The facility schedules dated July 2025 and August 2025 documents the facility did not have RN coverage on 7/18, 7/19, 8/9, 8/10, and 8/23/25. On 8/18/25 at 4:25 PM, V2 confirmed in email the facility did not have RN coverage on the above listed dates.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were administered as ordered for 1 of 1 (R5) resident reviewed for medication administration in the sample of 9. Findings Include:R5's facility Transfer/Discharge Report with a print date of 8/18/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability.R5's MDS (Minimum Data Set) dated 6/30/2025 documents a Brief Interview for Mental Status score of 15, indicating R5 is cognitively intact.R5's Order Summary Report Active Orders as of: 04/19/2025 includes the following physician order with a start date of 04/18/2025, Preservision AREDS 2 Soft gel Give 1 capsule orally one time a day for Supplement Take 1 Capsule by Mouth Once Daily (Supplement).R5's Medication Administration Records (MAR) dated 4/1/2025 through 4/30/25, 5/1/2025 to 5/31/2025, 6/1/2025 to 6/30/2025, 7/1/2025 to 7/31/2025, and 8/1/2025 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 ensure medications were available to be administered as ordered for 1 of 1 (R5) resident reviewed for pharmacy services in the sample of 9. Findings Include:R5's facility Transfer/Discharge Report with a print date of 8/18/25 documents R5 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability.R5's MDS (Minimum Data Set) dated 6/30/2025 documents a Brief Interview for Mental Status score of 15, indicating R5 is cognitively intact.R5's Order Summary Report Active Orders as of: 04/19/2025 includes the following physician order with a start date of 04/18/2025, Preservision AREDS 2 Softgel Give 1 capsule orally one time a day for Supplement Take 1 Capsule by Mouth Once Daily (Supplement).R5's Medication Administration Records (MAR) dated 4/1/2025 through 4/30/25, 5/1/2025 to 5/31/2025, 6/1/2025 to 6/30/2025, 7/1/2025 to 7/31/2025, and 8/1/2025 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 interview and record review, the facility failed to ensure Registered Nurse (RN) coverage 8 consecutive hours a day, 7 days per week. This failure has the potential to affect all 40 residents living in the facility. Findings Include: The facility's agency nursing time reports documented no RN was on shift for 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and 12/21/2024. On 3/13/2025 at 7:50 AM, V10 (Licensed Practical Nurse/LPN) stated there were some days in October 2024 - December 2024 that they did not have RN coverage for 8 consecutive hours a day. On 3/13/2025 at 10:05 AM, V2 (Director of Nursing) stated there were no RN punch times noted on the agency nursing reports for 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and 12/21/2024. On 3/13/2025 at 10:30 AM, V1 (Regional Director of Operations) stated the facility did not have documentation of a Registered Nurse on shift for at least 8 consecutive hours a day on 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and…

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

Based on observation, interview and record review the facility failed to properly maintain the hot water source to reach minimum washing temperatures in the dish machine and handle food properly to prevent cross contamination. These failures have the potential to affect all 40 residents residing in the facility. The Findings Include: 1. On 3/11/25 at 1:00 PM, the kitchen staff were in the process of washing the lunch dishes after the meal was served in the dish machine. When the temperature in the dish machine was checked with a kitchen provided calibrated thermometer, the water temperature was 80 degrees. At this time V5 (Dietary Manager) verified their dish machine was a low temperature dishwasher that uses chemical sanitization. V5 stated that they have trouble sometimes with the water temperatures because of the way the system works. V5 stated that they have two 40 gallon water heaters, but one of them feeds both the three compartment sink and the dish machine. V5 stated that she typically would like the water temperature above 110 degrees Fahrenheit. On 3/11/25 at 2:00 PM, V4…

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

Based on record review and interview, the facility failed to maintain documentation of holding quarterly Quality Assurance and Performance Improvement meetings (QAPI). This has the potential to affect all 40 residents residing in the facility. The Findings Include: During the investigation and review of facility records no evidence of quarterly QAPI meeting attendance or meeting information was found or produced by the facility. On 03/13/25 10:41 AM, V1 (Regional Director of Operations) stated the facility has been having quarterly QAPI meetings but she was unable to find any documentation of minutes or attendance sheets to show that the facility held quarterly QAPI meetings past 2/16/2024. The facility policy for Quality Assurance Performance Improvement Program with last revision date of 10/24/22 documents the following: Purpose: To ensure the organization has an organized quality assessment and improvement process program that includes performance measurement, performance assessment, and performance improvement and addresses the care and unique services provided by the facility.…

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 that dietary supplements were provided to residents as ordered for 4 (R4, R13, R19, and R20) of 4 residents reviewed for nutrition status in the sample of 27. The Findings Include: 1. R4's admission Record documents an admission to the facility on 1/13/2025 and included the following diagnoses: dementia, Vitamin D deficiency and Vitamin B12 deficiency. R4's current Physician Orders for diet are as follows: regular diet and mighty shakes twice a day for low Body Mass Index (BMI). R4's Care Plan has a focus area of: I have a potential nutritional problem. A goal for this focus area included: I will maintain adequate nutritional status daily through the review date. The interventions include: provide diet as ordered. 2. R13's admission Record documents an admission date of 8/25/2020 and included the following diagnoses: bipolar disease, anxiety, depression, and muscle wasting and atrophy. R13's current Physician Orders have a diet order of mighty shakes with meals for significant weight loss for 6 months,…

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 and record review, the facility failed to notify the proper authorities in an abuse investigation in 1 (R14) of 1 resident reviewed for abuse. The findings include: R14's admission Record documented admission to the facility on 2/13/25 and included diagnoses of peripheral vascular disease, heart failure, Type 2 Diabetes Mellitus, chronic pressure ulcers on right buttock, stage 3, non-pressure related chronic ulcers of left heel and mid foot and left lower leg. R14's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R14 is cognitively intact. The facility's Report to IDPH Regional Office documented an initial report dated 3/10/25, noting there was an allegation of staff to resident abuse (verbal). Actions taken included the CNA's (Certified Nurse Assistant's) in question were suspended, the physician and Power of Attorney (POA) were notified on 3/10/25. The document also notes an investigation was initiated. There was no…

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 behavioral interventions and procedures for suicide observation and prevention were provided to a resident with suicidal ideations for 1 (R23) of 1 resident reviewed for behavioral health services in the sample of 27. The findings include: R23's admission Record documents that she was admitted to the facility on [DATE] and included diagnoses of major depressive disorder, schizophrenia, borderline personality disorder, anxiety disorder, panic disorder, cognitive communication deficit, vascular dementia, moderate with psychotic disturbance, unspecified sequelae of cerebral infarction and epilepsy. R23's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating R23 has moderate cognitive impairment. Under the section for Mood, R23 is documented as having the following symptoms: Little interest or pleasure in doing things, feeling down, depressed, or hopeless, Trouble falling or staying asleep,…

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 and interview, the facility failed to safeguard medical record information against loss/destruction and ensure records were readily accessible for 3 (R2, R33, R38) of 3 residents reviewed in the sample of 27. The Findings Include: 1. R33's Electronic Health Record (EHR) included an admission Record documenting R33 admitted to the facility on [DATE]. R33's EHR was missing records dated prior to 1/29/25 (such as progress notes, behavior tracking, physician orders, etc.). 2. R38's EHR included an admission Record documenting R38 admitted to the facility on [DATE]. R38's EHR included an Minimum Data Set (MDS) assessment dated [DATE] documenting a discharge with return not anticipated assessment an listed a discharge status of Nursing Home (long-term care facility). R38's EHR was missing records dated prior to 1/29/25 (such as progress notes, physician orders, and a discharge summary, etc.). 3. R2's EHR included an admission Record documenting R2 admitted to the facility on [DATE]. R2's EHR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to timely remove discontinued medication from the working stock for 1 of 3 residents (R1) reviewed for medication storage in a sample of 7. The findings include: R1's admission Record documents an admission date of [DATE] and diagnoses including Parkinsonism, Paranoid Schizophrenia, Psychosis, Heart Failure, Anxiety, Hypertension, Schizoaffective Disorder, and Major Depressive Disorder. R1's Physician Orders dated [DATE] documents an order for Chlorpromazine 100mg IM every 6 hours as needed for Psychosis. Offer by mouth first give with Benztropine in same syringe. R1's Physician Orders for September, October, November, and [DATE] were reviewed with no orders noted for Chlorpromazine (Thorazine). R1's Medication Administration Record (MAR) for [DATE] was reviewed with no orders or documentation of the administration of Chlorpromazine (Thorazine) noted. On [DATE] at 3:15PM, V11 (Licensed Practical Nurse/LPN) stated she worked the evening of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility administration knowingly failed to report abuse allegations, thoroughly and timely investigate abuse allegations, suspend staff pending facility abuse investigations, and inaccurately document resident assessments for 3 of 5 residents (R26, R46, and R300) reviewed for administration in a sample of 14. This failure has the potential to affect all 47 residents residing in the facility. Findings include: 1. On 5/10/2024 at 11:20 AM, V38 PRSC (Psychiatric Rehabilitation Service Counselor) stated R300 came to her on Friday evening (5/3/2024) and reported an allegation of physical abuse. V38 stated R300 came to her and told her when he was out front a guy came up and wrapped his arms around R300 and threw R300 down. V38 stated I just didn't think it happened on dayshift. V38 said R300 described the guy that allegedly did this was Mexican and the facility did not have anyone employed that fit that description. V38 stated the way it was brought to me by (R300) didn't…

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 allow residents to choose to reside in the same room with their spouse and visit other residents for 2 out of 3 residents (R300 and R301) reviewed for resident rights in a sample of 14. Findings include: 1. On 5/8/2024 at 9:55 AM, R300 was interviewed and stated My wife lives here, and they made her move so they could put this man in here. My wife moved here from another facility so we could be together and now we can't be together. I can't go to her room and visit her because I cannot go past the double doors. (V34 Certified Nursing Assistant/ CNA) told me I cannot go down that hall through the double doors so I can't even get my haircut. R300's document titled admission Record documented an admission date as 4/5/2024 with diagnoses including: Intervertebral Disc Degeneration, Thoracic Region, Polyarthritis, Chronic Obstructive Pulmonary Disease, Atherosclerotic Heart Disease, Anemia, Vitamin D Deficiency, Hypertension, Mild cognitive impairment. R300's 4/15/2024 MDS (Minimum Data Set) documents the BIMS…

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 identify and report allegations of staff to resident verbal abuse immediately to the Administrator and failed to report and allegation of abuse to the Illinois Department of Public Health (IDPH) for 3 of 5 residents (R44, R46, and R300) reviewed for abuse in the sample of 14. Findings include: 1. R46's face sheet documented an initial admission date of 8/24/23 with diagnoses including: pulmonary hypertension, chronic obstructive pulmonary disease, post- traumatic stress disorder, attention- deficit hyperactivity disorder, hypothyroidism, anxiety disorder, depression, borderline personality disorder, mild intellectual disabilities, need for assistance with personal care. R46's 2/28/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating R46 was cognitively intact. On 5/8/24 at 9:56 AM, R46 said a CNA (Certified Nursing Assistant) told him to turn his fking music down. R46 said he (V32/CNA) was always…

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 Registered Nurse (RN) coverage 8 hours a day, 7 days per week. This failure has the potential to affect all 44 residents who reside in the facility. Findings Include: The facility's nursing schedules for February and March 2024 documented the following dates were lacking 8 hours of Registered Nurse (RN) coverage: 2/4/2024, 2/5/2024, 2/11/2024, 2/25/2024, 3/9/2024, 3/10/2024, 3/16/2024 and 3/17/2024. On 3/19/24 at 2:40 PM, V2 (Director of Nursing/DON) confirmed that the facility's February and March 2024 nursing schedules were accurate. On 3/19/24 at 2:46 PM, V1 (Administrator) confirmed the lack of Registered Nursing coverage on the above listed dates. V1 stated the weekend dates are difficult for them to get RN coverage. The Long-Term Care Facility Application for Medicare and Medicaid dated 3/19/24 documented a facility census of 44.

Based on observation, interview and record review, the facility failed to date and label opened food items/leftovers. This failure has the potential to affect all residents residing in the facility who receive food from the kitchen. The Findings Include: On 3/19/24 at 9:00 AM, during the initial tour of the kitchen, items in the refrigerator were found to be opened without identifying and dating the food. Items found not dated and labeled after opening were salad dressing, corn, tortillas, shredded cheese and a container of meat. At this time, V3 (Dietary Manager) stated that she has new employees that maybe do not know they need to do this. V3 further stated she was unsure what was even in the one container that appeared to be a type of meat. The facility's storage policy with a revision date of 10/20 documents that it is the policy of (Facility Name) that food shall be stored on shelves in areas that provide the best preservation. Food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food and food cost .5. Store leftovers in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This has the potential to affect all 44 residents residing in the facility. The findings include: On 03/19/24 at 09:56 AM, R7's room was observed to have gnats flying in the bathroom above the toilet. On 3/20/2024 at 08:54 AM, gnats were seen flying around in the dining room around a table and near the coffee bar. On 03/20/24 at 08:54 AM, V3 (Dietary Manager) stated there was a big problem with gnats and the facility has had them all winter. V3 stated, the gnats are always around the coffee station and garbage cans and there is a problem with one of the drains in the kitchen. V3 stated corporate maintenance is supposed to come fix it, but V3 didn't know when. On 03/20/24 at 02:20 PM, V1 (Administrator) acknowledged that the facility has had gnats. V1 stated that they do have an active pest control contract, and the facility was recently serviced. V1 stated…

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 keep resident care areas clean and in a good state of repair for 14 (R7, R18, R10, R16, R23, R21, R41, R45, R29, R22, R25, R35, R15, and R20) of 14 residents reviewed for homelike environment in the sample of 36. Findings Include: On 03/19/24 09:56 AM, R7's room was observed to have two brown stained ceiling tiles, a missing cover on the baseboard heater, and a brownish-orange discoloration to the floor near the baseboard under the sink. In R7's room and bathroom, chipped paint was noted on multiple areas of the walls as well as chipped wood on the door inside bathroom. On 03/19/24 at 10:17 AM, R18, R10 and R16's adjoining bathroom had missing baseboard with stained drywall exposed. On 03/19/24 10:21 AM, R23's room revealed the front cover was missing off the baseboard heater. The cover for a portion of the heater was lying on the floor in front of the heater. There were wood chunks missing out of the corner of the door and missing paint with wood exposed. On 03/21/2024 at 11:30 AM, R21, R41, and R45's shared…

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 timely completion of quarterly assessments for 4 (R5, R7, R26, R45) of 4 residents reviewed for quarterly assessments in the sample of 36. Findings Include: 1. R5's Profile Face Sheet documents an admission date of 5/21/19. This same document includes the following diagnoses: Schizoaffective Disorder, Major Depression Disorder, Anxiety, and Dementia. On 2/21/24 at 11:00 AM, V4 (Minimum Data Set/MDS Coordinator) stated that R5's quarterly MDS (Minimum Data Set) assessment was due on 2/7/24 and it was not completed and transmitted until 3/20/24. R5's current quarterly MDS Assessment Section Z was reviewed and noted to be signed by V4 and dated 3/20/24. 2. R7's Profile Face Sheet documents an admission date of 9/23/22. This same document includes the following diagnosrs: Major Depressive Disorder, Anxiety, and History of falling. On 2/21/24 at 11:00 AM, V4 stated that R7 had a quarterly MDS assessment due on 1/2/24 and it was not completed and transmitted until 3/11/24. R7's current quarterly MDS Assessment Section Z…

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 Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Clinical Health Record for 2 (R8, R151) of 2 residents reviewed for Advanced Directives in the sample of 36. 1. Review of R8's Profile Face Sheet documented an original admission date to the facility of [DATE]. Diagnoses listed on this same sheet included but were not limited to: Rhabdomyolysis; Acute Kidney Failure, Unspecified; Type 2 Diabetes Mellitus without complications, etc . R8's Illinois Department of Public Health Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form dated [DATE] documented orders for patient in cardiac arrest as, No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation. R8's Physician's Orders dated for [DATE] - [DATE] documented a code status of Full Code. R8's Care Plan documented a problem area for Advanced Directives as, No Advanced Directives chosen- Resident will be…

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

Based on interview and record review, the facility failed to ensure comprehensive assessments were completed in accordance with required time frames for 3 (R32, R23 and R151) of 3 residents reviewed for comprehensive assessments and timing in the sample of 36. Findings Include: 1. R23's Profile Face Sheet documents an admission date of 4/3/20, and includes the following diagnoses: Major Depressive Disoder, Dementia, Muscle Weakness and Aphasia. R23's most recent completed Minimum Data Set (MDS) was dated 10/11/23 and coded as a quarterly assessment. On 3/21/24 at 11:30 AM, V4 (MDS Coordinator) stated that R23 was due for a comprehensive annual MDS 1/16/24, but this was not completed and transmitted until 3/14/24. R23's current comprehensive annual MDS Section Z was reviewed and noted to be signed by V4 and dated 3/14/24. 2. R151's admission and Discharge Record documents an admission date of 1/31/24. This same document includes the following diagnoses: Anxiety, Depression, Skin Rash and Memory Impairment. On 3/20/24 at 2:00 pm, V4 stated that R151's MDS assessment had not been…

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

Based on record review and interview, the facility failed to implement a baseline care plan for 1 (R151) of 12 residents reviewed for baseline care plans in a sample of 36. Findings Include: R151's admission and Discharge Record documents an admission date of 1/31/24. This same document includes the following diagnoses: Spinal Stenosis, Physical Deconditioning, Anxiety, Memory Impairment and Depression. Review of R151's medical record revealed no care plan could be found. On 3/20/24 at 2:34 PM, V4 (Minimum Data Set [MDS]/Care Plan Coordinator) stated that she does not have a care plan (Comprehensive or Baseline) started. V4 further stated that usually the nurses start the baseline care plan on admission or within 24-48 hours of admission, and then she creates the comprehensive care plan. The Baseline Care Planning policy with a revision date of 3/16/22 documents 3. the 'Baseline Care Plan' and 'Care Plan Summary' shall be completed within 48 hours of admission by the admitting nurse or designee .

Based on interview and record review, the facility failed to revise a comprehensive plan of care to meet current resident needs for 2 (R28 and R34) of 13 residents reviewed for care plan timing and revision in the sample of 36. Findings Include: 1. Review of R28's admission and Discharge Record documented an original admit date to the facility of 10/20/23. R28's Cumulative Diagnosis Log documented diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, Hyperglycemia, Weakness, Developmental Disorder, etc . R28's Nurse's Notes document on 11/13/23 at 2:00 PM, an entry detailing the onset of a new 1 centimeter by 1 centimeter open area on his left buttock. An additional entry on 3/20/24 at 6:00 PM, documented an evaluation was made by V11 (Wound Physician), in which the wound to R28's left buttock was determined to be resolved as of this date. On 3/21/24 at 1:10 PM, V4 (Minimum Data Set/Care Plan Coordinator [MDS/CPC]) confirmed that R28's current plan of care did not, and had not included a revision to incorporate a focus area for current or the 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 offer pneumococcal and/or covid vaccinations in accordance with guidelines for 2 (R15 and R41) of 5 residents reviewed for immunizations in a sample of 36. Findings include: 1. R15's Profile Face Sheet documents an admission date of 7/27/2018, and a date of birth (DOB) indicating R15 is [AGE] years of age. R15's face sheet documents diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Essential Hypertension, Malignant Neoplasm of Prostate, Peripheral Vascular Disease, Atherosclerosis of the aorta, Atherosclerotic Heart Disease of native coronary artery. The facility document titled Resident Immunization Tracking Log dated 10/1/2023 through 3/31/2024 documents R15 received the PCV13 (Pneumococcal Conjugate Vaccine) on 12/20/2022. No documentation could be found in R15's medical record of R15 having been offered or administered a PCV (Pneumococcal Conjugate Vaccine) 20 or PPSV (Pneumococcal Polysaccharide Vaccine) 23 vaccine. 2. R41'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.